UC-NRLF 


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THE  ORGANIZATION 

AND 

ADMINISTRATION 

OF  THE 

HEALTH    DEPARTMENT 

OF 

SPRINGFIELD,  MASS. 


REPORT  OF  A  SURVEY 

Made  by  the 

SPRINGFIELD 
BUREAU  OF  MUNICIPAL  RESEARCH 

APRIL,   1914 


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fUSlIC  EEiJMH  LIB. 


FRAIIK  U  KEtlY,  Hi.  O, 


FOREWORD 


THERE  is  submitted  herewith  for  public  consider- 
ation a  report  of  a  detailed  survey  of  the  organiza- 
tion and  administration  of  the  Health  Depart- 
ment, pointing  out  defective  conditions  obtaining  in 
the  department's  organization  and  administration  and 
definite  constructive  suggestions  for  the  improvement 
of  the  efficiency  of  the  operation  of  this  department  and 
of  its  service  to  the  public. 

The  survey  and  the  report  thereon  was  made  for  the 
Mayor  and  the  Springfield  Bureau  of  Municipal  Research 
by  Dr.  Carl  E.  jMcCombs  of  the  New  York  Bureau  of 
Municipal  Research. 

An  endeavor  has  been  made  to  present  an  honest 
and  impartial  report  of  existing  conditions  with  a  view 
to  supporting  the  Health  Department  in  the  progressive 
steps  it  has  taken,  of  stimulating  citizen  and  institutional 
cooperation,  and  of  advancing  progressive  recommend- 
ations for  increasing  the  department's  efficiency.  The 
report  is  in  no  sense  meant  as  a  destructive  criticism. 
In  every  sense  and  relation  it  is  meant  to  be  constructive. 

Springfield  Bureau  of  Municipal  Research. 


MS03158 


TABLE  OF   CONTENTS 

Page 

Summary  of  Recommendations 4 

Summary  of  Criticisms 5 

Appropriations 8 

Appropriations  for  Health  Service  Liberal 8 

Increased  Appropriations  for  1914 9 

Budget  Schedules  Not  Itemized 10 

Too  Much  Appropriated  for  Medical  Inspectors 11 

Revenue 12 

Receipts  from  License  Fees,  Etc 12 

Time  Records  Important  in  Determining  Charges  for  Removal  of  Nuisance  12 

Administration 13 

Board  of  Health  Unnecessary 13 

Division  of  Authority  Hampers  Efficient  Control 13 

Full  Time,  Adequately  Paid,  Trained  Service  Needed 14 

Prevention  of  Transmissible  Diseases 15 

Reporting  of  Diseases  Dangerous  to  Public  Health 15 

More  Careful  Investigation  of  Typhoid  Cases  Needed 15 

Need  for  Investigation  of  Diphtheria  and  Scarlet  Fever 16 

Aids  to  More  Complete  Reporting  of  Disease 16 

Registration  and  Control  of  Tuberculosis 17 

Tuberculosis  Register  Should  Be  Revised 17 

Placards  Should  Be  Understood  by  Laymen 18 

Quarantine,  Disinfection,  and  Quarantine  Release 18 

Better  Records  of  Disinfection  Needed 18 

Laboratory  Service  a  Valuable  Aid  in  Prevention  of  Disease 19 

Laboratory  Service  Should  Be  Extended 19 

Laboratory  Reports  Should  Not  Be  Made  on  Post  Cards 20 

Protection  of  the  Health  of  Children 21 

Birth  and  Death  Records  Important 21 

Low  Infant  Mortality  Rate 21 

Extension  of  Child  Welfare  Service 21 

Child  Welfare  Nurse  Recommended 22 

Supervision  of  Midwives  Needed 22 

Preventive  Campaign  Needed 23 

Supervision  of  Day  Nurseries,  Infant  Boarding  Houses,  and  Children  in 

Institutions 23 

Infant  Mortality  Charts  Would  Be  Helpful 24 

Duties  of  Medical  Inspectors 24 

Records  of  Service  Performed  Inadequate 24 

Time  Records  Valueless 25 

Need  for  More  Thorough  Physical  Examinations 26 

Records  of  Defects  of  Teeth  Incomplete 26 

School  Dental  Clinic  Needed 27 

School  Medical  Clinic 27 


Page 

Visits  Should  Be  Made  Daily 28 

Duties  of  School  Nurses 28 

Nurses  Should  Render  Time  Reports 29 

Yearly  Sanitary  Survey  of  Schools  Recommended 29 

Salaries  of  School  Physicians  Ample 30 

Approved  Record  Forms  Recommended 30 

Protection  of  Food  Supply 31 

Health  Department  Hampered  by  State  Act 31 

Inspector  of  Meats,  Provisions,  and  Slaughtering 31 

Improved  Records  Needed 32 

Inspectors  Should  Be  By  Assignment  Only 32 

Duplication  of  Work 32 

Milk  Inspection  Service  Excellent 33 

Minimum  Score  for  Dairies 33 

Bacteriological  Analysis  Shows  Improvement  of  Milk  Supply 33 

Stores  and  Restaurants  Inspected 34 

Spirit  of  Co-operation  Commendable;  Dairy  Scores  Should  Be  Published  . .  35 

Cost  of  Country  Milk  Inspection  Could  Be  Reduced 35 

Records  of  Milk  Laboratory  Well  Kept 36 

Sanitary  Inspection 37 

Organization  of  Inspection  Service 37 

Motor  Cycles  for  Sanitary  Inspectors 37 

Time  Wasted  in  Transcribing  Reports;  New  Procedure  Suggested 37 

Inspections  Should  Be  By  Assignment 38 

Inspectors  Should  Be  Districted 38 

Improved  Reports  Recommended 3S 

Nurses  Should  Be  Used  as  Sanitary  Inspectors  in  Summer  Months 39 

School  Children  in  *'  Clean-up  "  Campaigns 39 

Policemen  as  Sanitary  Inspectors 39 

Citizens'  Complaints  Should  Be  Encouraged 39 

Vital  Statistics 41 

Vital  Statistics  Not  Kept  in  Health  Department 41 

Death  Certificates  Should  Be  Properly  Made  Out 41 

Cemetery  Returns  Not  Rquired 42 

Publicity 43 

Publicity  —  An  Agency  for  Improved  Health  Control 43 

News  Articles  of  Health  Interest 43 

Weekly  or  Monthly  Bulletins 43 

Exhibits,  Lectures,  Etc 43 

Manual  Now  Being  Prepared 44 

The  Health  Department  Hospital 45 

Hospital  Service  Commendable 45 

Better  Accommodations  for  Nurses  Needed 45 

Improved  Stores  Records  Should  Be  Required 46 

Use  of  Private  Laundry  Dangerous 47 

Saving  in  the  Purchase  of  Milk  Probable 47 

Cultivation  of  Land  Recommended 48 


SUMMARY  OF  RECOMMENDATIONS 

1  —  The  abolition  of  the  present  board  of  health 

2  —  The  appointment  of  a  single  full-time  trained  health  officer  who 

shall  be  the  executive  head  of  the  health  department 

3  —  More  detailed  and  accurate  information  with  all  supporting  data 

regarding  the  health  department's  requests  for  appropriations 

4  —  Wider    cooperation   with    physicians,    nurses,    sanitary     officers, 

police,  charity  organizations,  and  others  in   the   registration 
of  cases  of  disease 

5  —  More  thorough  investigation  of  all  cases  of  diseases  dangerous  to 

public  health 

6  —  Revision  of  the  tuberculosis  register 

7  —  More  complete  and  detailed  records  of  disinfection 

8  —  Improvement  of  laboratory  facilities  by  the  removal  of  the  labora- 

tory to  the  municipal  building 

9  —  Extension  of  laboratory  service  by    improved  cooperation  with 

physicians 

10  —  The  appointment  of  a  child  welfare  nurse 

11  —  Registration  and  supervision  of  midwives 

12  —  Regular  inspection  and  proper  records  of  day  nurseries,  infant 

boarding  houses,  and  other  institutions  caring  for  children 

13  —  The  keeping  of  infant  mortality  charts  showing  where  work  is 

needed 

14  —  More  thorough  physical  examinations  of  school  children 

15  —  Improved  records  of  defective  conditions  found  through  a  medical 

inspection  of  school  children  and  of  the  efforts  made  to  rem- 
edy them 

16  —  Improved  facilities  for  medical  and  dental  care  of  school  children 

17  —  Daily  visits  to  schools  by  medical  inspectors 

18  —  Improved  records  of  sanitary  conditions  in  schools  and  a  yearly 

sanitary  survey  of  each  school 

19  —  Better  supervision  of  the  city's  food  supply 

20  —  Reorganization  of  inspection  service   to  prevent  duplication  of 

work 

21  — The  establishment  of  a  minimum  score  for  dairies 

22  —  More  frequent  bacteriological  examination  of  milk  samples 

23  —  The  establishment  of  a  maximum  bacterial  standard 

24  —  Publication  of  dairy  scores  and  bacterial  counts 

25  —  The  provision  of  motorcycles  for  the  country  milk  inspector  and 

for  sanitary  inspectors 

26  —  The  use  of  the  two  additional  inspectors  authorized  for  1914  as 

food  and  milk  inspectors  rather  than  as  sanitary  inspectors 


27  —  All  inspections  to  be  by  definite  assignment  and  based  on  indi- 

vidual records  of  places  requiring  inspection 

28  —  Districting  of  inspectorial  staff 

29  —  Securing  the  cooperation  of  nurses,  school    teachers,  and  school 

children  in  a  continuous  year  round  clean-up  campaign 

30  —  Cooperation  with  police  department    in  using  policemen  as  health 

inspectors 

31  —  Requiring  the  city  clerk's  office  to  furnish  the  health  department 

with  copies  of  all  birth  and  death  records  —  until  such  time 
as  registration  of  vital  statistics  may  be  placed  wholly  in 
the  control  of  the  health  department 

32  —  The  enforcement  of  all   regulations  regarding  the  reporting  of 

births  and  deaths 

33  —  Requiring  cemeteries  to  render  reports  of  all  interments 

34  —  Immediate  revision  of  the  sanitary  code 

35  —  Wider  publicity  of  health  facts  by  means  of  bulletins,  lectures, 

exhibits,  and  improved  annual  report 


SUMMARY  OF  CRITICISMS 

1  —  Control  of  daily  health  activities  and  needs  by  a  health  board, 

elected  by  council  without  other  qualifications  than  that 
one  member  shall  be  a  physician,  meeting  but  twice  a  month, 
and  without  personal  contact  with  and  knowledge  of  health 
conditions  hampers  rather  than  expedites  health  control 

2  —  There  are  at  present  two  health  officers  —  the  health  physician, 

who  is  a  member  of  the  board  of  health,  and  the  health  agent 
who  is  an  executive  officer  and  not  a  member  of  the  board. 
Control  of  various  health  functions  is  divided  between  those 
two  officers  each  of  whom  considers  himself  the  head  of  the 
department 

3  —  The  health  budget  estimates  for  1914  were  not  only  incorrectly 

prepared  but  incomplete  in  explanation  of  reasons  why  cer- 
tain sums  were  needed 

4  —  No  attempt  has  been  made  to  improve  registration  of  diseases 

by  wide  publicity  and  cooperation  with  both  physicians  and 
laymen.  It  is  estimated  that  there  are  each  year  150  to  200 
unreported  cases  of  typhoid  fever 

5  —  Investigation  of  cases  of  disease  dangerous  to  public  health  by 

a  lay  sanitary  inspector  is  inadequate  for  many  diseases. 
There  is  insufficient  study  of  possible  sources  of  diphtheria, 
scarlet  fever  and  typhoid  fever 


6  —  The   tuberculosis   register  has   not  been   kept   up-to-date,   some 

records  dating  as  far  back  as  1905  without  subsequent  entry 
as  to  later  condition 

7  —  Disinfection  records  do  not  show  time  spent  by  inspectors,  quan- 

tities of  disinfectant  used,  room  space  fumigated,  or  other 
action  taken  although  information  on  these  points  is  essen- 
tial in  determining  the  efficiency  of  service 

8  —  The  present  quarters  of  the  health  laboratory  in  a  private  build- 

ing are  poorly  arranged,  badly  lighted  and  inconveniently 
equipped 

9  —  Laboratory  reports  of  examination  of  specimens  are  mailed  to 

physicians  on  post-cards  which  contain  the  name  of  the 
patient  and  the  laboratory  findings.  Confidential  relations 
between  patient  and  physician  are  thus  violated 

10  —  Although  the  department  of  health  requested  a  child  welfare  nurse 

for  1914  this  request  was  denied  by  council;  The  preserva- 
tion of  the  health  of  children  demands  increased  facilities  and 
an  effective  program 

11  —  Midwives  are  unsupervised  and  unregulated,  although  statistics 

show  that  from  10  to  30  percent  of  babies  are  attended  at 
birth  by  midwives.  There  are  14  cases  of  opthalmia  neona- 
torum (a  disease  causing  blindness  in  babies)  and  67  cases  of 
inflamed  eyes  in  1913  —  all  such  cases  are  due  to  improper 
care  of  the  babies*  eyes  at  birth,  either  by  physician  or  mid- 
wife or  other  attendant 

12  —  Aside  from  the  inspection  required  by  law  before  licensure  of 

infant  boarding  houses  or  day  nurseries  the  board  of  health 
requires  no  further  inspection  or  supervision 

13  —  Infant  mortality  charts  showing  when  infant  mortality  is  highest 

and  when  lowest  are  not  kept,  although  infant  mortality  is  an 
unfailing  index  to  health  needs 

14  —  Records  show  that  physical  examinations  of  school  children  are 

not  thoroughly  made.  Springfield  medical  inspectors  found 
only  1.2  percent  of  children  with  enlarged  tonsils,  adenoids, 
and  defective  breathing,  while  other  cities  show  that  from 
10  to  50  percent  of  school  children  suffer  from  such  defects. 
Some  Springfield  medical  inspectors  report  from  20  to  24 
physical  examinations  per  hour 

15  —  Records  of  medical  inspection  of  school  children  and  of  the  nurses* 

efforts  to  remedy  conditions  are  inadequate.  No  figures  are 
given  in  the  department's  report  for  1913  of  the  number  of 
children  having  defective  teeth  and  how  such  defects  were 
cared  for 


16  —  No  facilities  are  provided  for  dental  care  of  children  or  for  medical 

service  in  treating  minor  diseases  of  injuries  which  are  so 
common  among  school  children  and  so  often  neglected 

17  —  Physicians  visit  schools  only  twice  each  week,  although  proper 

control  of  the  health  of  children  requires  daily  supervision 
by  a  physician 

18  —  No  detailed  reports  of  the  sanitary  conditions  of  school  buildings 

are  made,  although  physicians  are  required  to  report  monthly 
as  to  whether  conditions  are  "  good,"  "  fair,"  or  "  bad." 
Such  reports  are  of  little  value  in  determining  the  sanitary 
needs  of  the  schools 

19  —  There  is  no  rule  or  regulation  of  the  board  of  health  prohibiting 

the  exposure  of  foods  to  dust  and  street  filth  and  this  unsan- 
itary practice  may  be  observed  daily 

20  —  The  inspector  of  meats  and  provisions,  the  milk  inspector  and  the 

sanitary  inspectors  are  in  many  instances  visiting  the  same 
place.  Duplication  of  inspection  means  money  and  time 
wasted 

21  —  The  milk  regulations  do  not  specify  a  minimum  score  for  dairies 

although  dairies  scoring  below  fifty  should  be  properly  con- 
sidered as  unfit  to  produce  milk  for  human  consumption 

22  —  Bacteriological   examinations   of   milk   samples   are   infrequently 

made.  Only  702  samples  were  thus  examined  in  1913,  —  an 
average  of  one  examination  a  year  for  each  supply 

23  —  The  milk  regulations  of  the  board  do  not  fix  a  maximum  bacterial 

count,  and  it  is  therefore  possible  for  milk  containing  a  dan- 
gerously high  number  of  bacteria  to  be  sold  for  human  con- 
sumption 

24  —  Although  the  citizen  may  have  access  to  all  milk  records,  no  pub- 

licity is  given  in  the  annual  report  or  elsewhere  as  to  the 
quality  of  milk  sold  by  the  individual  dealers 

25  —  The  milk  inspector  spends  about  $600  each  year  for  transporta- 

tion in  visiting  country  dairies.  A  motorcycle  would  cost 
$250  and  approximately,  one  cent  a  mile  for  service 

26  —  Three  sanitary  inspectors  on  motorcycles  could  do  as  much  work 

or  more  than  six  inspectors  not  so  equipped 

27  —  Two  additional  sanitary  inspectors  as  authorized  for   1914  are 

not  needed.  These  additional  inspectors  could  be  used  to 
better  advantage  in  the  inspection  of  milk  and  other  foods 

28  —  Inspectors  are  not  sent  out  on  definite  assignments  based  on  indi- 

vidual records  of  places  requiring  inspection.  Lacking  such 
individual  records  assignments  are  either  not  made,  in  which 


case  inspection  is  often  of  a  hit  or  miss  variety,  or  made  and 
reported  on  without  adequate  check  as  to  service  performed 

29  —  Inspectors  are  not  districted,  although  this  is  a  valuable  provision 

for  fixing  responsibility  and  preventing  duplication  of  effort 

30  —  School  nurses  are  employed  in  the  summer  months  as  aids  to  the 

Baby  Feeding  Association  and  the  Tuberculosis  Association. 
Their  work  could  be  made  of  more  value  to  the  health  depart- 
ment by  requiring  that  they  keep  careful  record  of  all  sanitary 
conditions  needing  the  supervision  of  the  health  department 

31  —  No  attempt  has  been  made  to  organize  school  children  for  ser- 

vice in  child  welfare  work  or  sanitary  control,  although  other 
cities  have  found  their  aid  invaluable 

32  —  Policemen  are  not  required  to  report  unsanitary  conditions  or 

health  violations  although  this  is  successfully  practiced  else- 
where 

33  —  The  city  clerk  is  the  registrar  of  vital  statistics  and  is  required 

only  to  furnish  a  daily  list  of  births  to  the  health  department. 
All  other  records  must  be  copied  by  the  health  department 
clerks.  Vital  statistics  are  of  value  to  the  health  depart- 
ment in  prevention  of  disease  and  death,  but  of  no  value  to 
the  city  clerk  except  for  statistical  purposes 

34  —  Deaths  are  not  reported  according  to  the  international  list  of  the 

causes  of  death,  although  this  is  the  accepted  standard  and  the 
one  adopted  by  the  Massachusetts  state  health  authorities 

35  —  Cemeteries  do  not  furnish  statements  of  interments,   although 

such  statements  would  furnish  a  valuable  check  on  the  effi- 
ciency of  death  registration 

36  —  The  sanitary  code  is  out  of  date  and  of  no  value  as  a  manual  for 

the  instruction  of  employees  and  citizens 

37  —  Publicity  is  inadequate.     Aside  from  the  annual  report  and  occa- 

sional leaflets  relating  to  health  regulations  citizens  are  not 
informed  as  to  health  conditions  and  health  department 
activities 


fRANK  L.  KSLLY,  M.  D. 


APPROPRIATIONS 

Appropriations  for  Health  Service  Liberal 

The  health  department  has  been  allowed  $63,288  for  13  months 
ending  January  1,  1915.  This  gives  a  per  capita  cost  of  conservation 
of  health  of  approximately  53  cents  on  a  12  month  basis,  which  places 
Springfield  well  in  the  forefront  of  American  cities  as  regards  provi- 
sion for  health  service.  New  York  City  with  its  extended  organization 
along  all  lines  of  health  work  spent  only  57  cents  per  capita  for  health 
conservation  in  1912,  according  to  the  United  States  census  report. 
Dayton,  Ohio,  has  recently  effected  a  complete  reorganization  of  its 
health  service,  giving  the  city  for  the  first  time  in  its  history  a  pro- 
gram and  facilities  for  adequate  health  protection  and  education  at  a 
per  capita  cost  of  34  cents. 

The  following  table,  based  upon  the  census  report  for  1912,  shows 
the  comparative  cost  of  health  conservation  in  15  American  cities  of 
50,000  to  100,000  population: 

Holyoke,  Mass 54c.  per  capita 

Somerville,  Mass 46c.  "         " 

Jacksonville,  Fla 46c.  "         " 

Savannah,  Ga 46c.  "         " 

Springfield,    Mass 43c. 

Lynn,  Mass 42c. 

Brockton,  Mass 34c.  " 

Sacramento,  Cal 32c  " 

Houston,  Tex 29c.  " 

Manchester,  N.  H 27c.  " 

Troy,  N.  Y 26c.  " 

Waterbury,  Conn 25c.  " 

Passaic,  N.  J 24c.  " 

Elizabeth,  N.  J 23c.  " 

Schenectady,  N.  Y 22c.  " 

Springfield  is  to  be  congratualted  on  the  liberality  of  its  appropri- 
tions,  but  there  is  no  doubt  that  reorganization  of  its  health  service 
would  give  more  effective  control.  The  problem  is  not  how  to  reduce 
health  appropriations,  for  many  authorities  believe  that  cities  in  Spring- 
field's class  (from  50,000  to  100,000  population)  should  spend  at  least  85 
cents  per  capita,  but  so  to  control  expenditures  through  efficient  organi- 
zation that  maximum  service  may  be  obtained  at  minimum  cost. 


a  (( 


Increased  Appropriations  for  1914 

The  appropriations  for  1914  as  compared  with  the  expenditures  for 
1913  are  summarized  as  follows: 

1913  Expended  1914  Requested       1914  Allowed 

(12  Months)  (13  Months)         (13  Months) 

Board  of  health $14,616.64        $21,813.31       $19,813. 

Isolation  hospital 28,547.54  88,635.00        32,200. 

Inspection  of  school  children  ...       5,702.92  11,275.00         11,275. 

$48,867.10    *$121,723.31      $63,288. 

The  present  budget  of  $63,288  provides  for  certain  additional 
services  according  to  the  schedule  prepared  by  the  health  department 
as  follows: 

Two  sanitary  inspectors  at  a  maximum  salary  of  $1200 
(These  inspectors  will  be  appointed  later  in  the  year) 

Inspector  of  slaughtering 

(The  present  inspector  of  meats  and  provisions  to  receive  $300  addi- 
tional salary  for  this  service) 

Clerk  in  office  of  health  department  at  $10  per  week 

Additional  nurses  at  isolation  hospital 

(Number  and  yearly  salary  not  specified) 

Ward  maid  at  isolation  hospital 
(Salary  not  specified) 

Additional  nurse  for  medical  inspection  from  March  1st,  at  $65  per 

month 
Laboratory  helper  at  $10  per  week 
Provision  has  been  made  for  salary  increases  as  follows : 

Health  physician  from  $1500  to  $1800 

Thirteen  medical  inspectors  up  to  March  1,  1913  were  paid 
$25  per  month  for  10  months;  they  now  receive  $50  per 
month  for  10  months 


Budget  Schedules  Not  Itemized 

Lack  of  itemization  of  budget  schedules  results  in  inability  on  the 
part  of  the  examiner  to  determine  specifically  the  need  for  certain 
requests.  It  is  impossible  to  discover,  except  through  personal  inter- 
views with  health  officials,  how  estimates  were  made  or  specifically  how 
appropriations  are  to  be  used.  Requests  for  additional  service  by  per- 
manent employees  and  temporary  employees  are  lumped  together 
without  explanation.  The  need  for  more  detailed  itemization  of  bud- 
get schedules  is  clear.     Without  such  itemization  it  is  impossible  for 

•  This  amount  was  increased  by  requests  for  $45,000  for  an  administration  build- 
ing and  $10,000  for  a  smallpox  hospital. 

10 


the  mayor  or  anyone  else  to  determine  from  the  estimate  sheets  pre- 
sented by  the  health  department  what  is  needed  or  why  it  is  needed. 
For  example,  "  additional  nurses  "  are  requested  at  the  isolation  hos- 
pital, but  no  statement  is  made  as  to  how  many  nurses  are  needed  or 
what  salaries  they  are  to  be  paid.  Some  of  the  nurses  employed  at  the 
isolation  hospital  receive  $600  per  year,  others  receive  $480.  Again, 
$2180  is  requested  for  salaries  of  ward  maids  at  the  isolation  hospital 
for  13  months.  There  are  six  ward  maids  at  $20  per  month,  and  an 
additional  ward  maid  is  requested  at  the  same  monthly  rate.  Six  ward 
maids  at  $20  per  month  for  13  months  will  cost  $1560.  One  additional 
ward  maid  at  $20  per  month  for  13  months  will  cost  $260.  The  total 
amount  actually  specified  in  the  health  department's  schedule  for  per- 
manent service  should  have  been  $1820.  It  is  not  specified  how  the 
remaining  $360  is  to  be  used,  and  although  the  clerk  of  the  department 
says  this  amount  is  designed  to  cover  extra  service  which  may  be  required, 
extra  service  in  1913  cost  but  $35. 

Too  Much  Appropriated  for  Medical  Inspectors 

In  calculating  the  amount  required  for  medical  inspectors  during 
the  coming  year,  the  department  based  its  estimates  upon  13  inspectors 
at  $50  per  month  for  the  13  months'  period  from  December  1,  1913  to 
January  1,  1914,  although  medical  inspectors  are  employed  only  10 
months  of  each  year  and  will  be  employed  only  11  months  during  the 
period  December  1,  1913  to  January  1,  1915.  The  department  requested 
therefore  $8450  for  medical  inspection  service  and  this  was  allowed, 
although  only  $7,150  should  have  been  requested  and  allowed  as  no 
additional  inspectors  were  asked  for  or  needed. 


11 


REVENUE 

Receipts  from  License  Fees,  Etc. 

A  small  amount  of  revenue  is  derived  by  the  city  through  fees  for 
licenses  and  payments  for  services  rendered  by  the  health  department  in 
removing  nuisances.  During  1913  the  sum  turned  over  to  the  city  by 
the  health  department  amounted  to  $395.60,  as  follows: 

Licenses  for  massage  and  vapor  baths  (Required 

by  state  act  at  $1  per  year) $5 .00 

Annual  milk  licenses  (678  at  50  cents) 339 .  00 

License  to  remove  dead  animals 1 .  00 

Payments  for  removal  of  nuisances 50 .  60 

Total  receipts $395.60 

Time  Records  Make  Charges  for  Removal  of  Nuisances  Accurate. 

The  present  practice  of  the  health  department  is  to  take  such  steps 
as  may  be  necessary  to  remove  temporary  nuisances  when  it  is  impos- 
sible to  compel  owners  or  agents  to  do  so  promptly.  In  such  cases  the 
department  is  empowered  to  collect  the  cost  of  removal  from  the  owner 
or  agent.  This  is  a  proper  procedure,  as  it  results  in  the  prompt  removal 
of  nuisances  which  otherwise  would  have  to  await  an  action  against  the 
owner  or  agent  of  the  premises.  The  fixing  of  costs  depends  upon  the 
action  of  the  board  of  health,  and  the  amount  is  supposed  to  cover  not 
only  the  actual  cost  of  removal  but  also  the  time  required  on  the  part 
of  the  sanitary  inspectors.  Without  time  records,  however,  it  is  im- 
possible to  estimate  accurately  the  proper  amount  of  charge  for  this 
service. 


12 


ADMINISTRATION 

Board  of  Health  Unnecessary 

The  board  of  health,  which  is  charged  with  health  administration, 
consists  of  three  members  elected  by  council  for  a  term  of  three  years, 
one  member  being  elected  each  year.  Under  the  ordinance  creating  the 
board,  it  is  required  that  at  least  one  member  of  the  board  shall  be  a 
physician,  who  shall  be  called  the  health  physician.  There  are  no  other 
qualifications  for  members  except  that  they  shall  not  be  members  of 
the  city  council  and  that  not  more  than  two  shall  be  chosen  from  one 
political  party.  From  this  last  provision  it  is  clear  that  the  framers  of 
the  ordinance  feared  political  bias  on  the  part  of  the  board,  and  the 
experience  of  other  cities  proves  that  their  fears  were  not  groundless. 

The  board  meets  twice  each  month  or  oftener  when  necessary  to 
decide  upon  emergency  matters.  Aside  from  the  physician,  who  is  a 
member  of  the  board,  the  selection  of  the  personnel  is  entirely  arbitrary 
on  the  part  of  the  council.  The  other  two  members  may  or  may  not 
know  the  city's  health  needs.  If  they  are  laymen  they  must  depend 
upon  the  advice  of  the  physician  member. 

A  board  of  health,  not  thoroughly  familiar  with  modern  health 
movements,  dominated  perhaps  by  personal  or  partisan  bias,  and  meet- 
ing only  infrequently,  is  not  an  effective  agency  for  energetic  action  upon 
health  problems.  It  is  the  experience  of  progressive  cities  generally 
that  such  a  board  is  an  antiquated  appendage  of  the  local  government. 
It  is  recommended,  therefore,  that  as  soon  as  practicable  the  board  of 
health  of  Springfield  be  abolished,  and  that  its  authority  be  vested  in  a 
single  health  commissioner  or  health  officer. 

Division  of  Authority  Hampers  Efficient  Control 

Health  administration  in  Springfield  is  hampered  by  a  division  of 
authority.  The  member  of  the  board  who  is  a  physician  is  known  as 
the  health  physician,  and  if  more  than  one  member  of  the  board  is  a 
physician,  the  council  elects  one  as  health  physician. 

The  duties  of  the  health  physician  as  prescribed  by  ordinance  are 
"  To  perform  all  such  medical  and  sanitary  duties  as  may  be  required 
by  the  board  of  health  and  the  mayor  and  the  city  council.  He  shall 
attend  the  meetings  of  the  board;  shall  make  all  bacteriological  exami- 
nations and  shall  perform  such  other  duties  as  may  be  prescribed  by 
ordinance.  In  case  of  the  prevalence  of  impending  or  any  infectious  or 
contagious  disease  within  the  city,  he  shall  give  to  the  mayor  or  either 
board  of  the  city  council  such  professional  advice  as  may  be  required  by 
any  of  them." 

13 


This  ordinance  seems  to  imply  that  the  health  physician  is  to  act 
as  the  chief  executive  of  the  health  department,  but  in  practice  this  is 
not  the  case.  The  board  of  health  is  given  power  under  the  ordinance 
which  creates  it  to  appoint  a  health  agent  (now  under  civil  service), 
and  the  health  agent  has  become  to  be  in  fact  the  executive  head  of  the 
health  department.  The  present  health  agent  thus  defines  his  own 
position:  "  When  the  board  of  health  is  in  session,  the  health  physician 
is  the  head  of  the  department.  When  it  is  not  in  session  I  am  the  execu- 
tive head." 

Full  Time,  Adequately  Paid,  Trained  Service  Needed 

Springfield  needs  a  full-time  trained  health  officer,  with  power  to 
act  as  the  direct  representative  of  the  mayor  or  council.  He  need  not 
be  a  physician,  but  he  should  be  thoroughly  trained  in  modern  health 
service.  He  should  have  the  ability  to  organize  his  department  effi- 
ciently; to  develop  a  program  for  health  control  along  all  lines;  to  anti- 
cipate health  dangers  and  provide  the  necessary  means  to  prevent  them ; 
to  secure  the  repeal  of  hampering  legislation  wherever  necessary;  to 
cooperate  with  all  existing  agencies  for  health  service  or  social  better- 
ment; to  carry  on  a  wide-spread  campaign  for  publicity.  Such  a  health 
officer  should  be  adequately  paid  not  less  than  $2500  per  year,  prefer- 
ably $3000.  The  state  civil  service  commission  should  be  requested 
to  conduct  an  examination  for  a  health  officer;  and  the  selection  of  a 
man  for  this  responsible  position  should  depend  not  upon  his  residence 
in  Springfield,  or  even  the  state  of  Massachusetts,  but  upon  his  ability 
to  meet  the  requirements  above  named.  If  a  Springfield  citizen  can  be 
found  who  meets  the  requirements,  well  and  good ;  but  Springfield  should 
be  satisfied  with  nothing  less  than  the  best  when  it  is  within  its  power 
to  secure  the  best. 

The  civil  service  commission  has  the  power  to  waive  all  restrictions 
as  to  residence,  if  in  its  opinion  the  needs  of  the  public  service  may  so 
require.  An  open  competitive  examination  for  the  position  of  health 
officer  in  the  city  of  Springfield  would  attract  many  men  of  proven 
ability  in  health  administration. 


14 


PREVENTION  OF  TRANSMISSIBLE  DISEASES 

Reporting  of  Diseases  Dangerous  to  Public  Health 

Those  diseases  which  are  specified  by  the  state  board  of  health  as 
**  dangerous  to  public  health  "  must  be  reported  to  the  health  depart- 
ment and  supervised  by  it  according  to  the  rules  of  the  state  board. 
Prompt  and  complete  reporting  of  diseases  dangerous  to  public  health  is 
imperative  if  prevention  is  to  be  effective.  The  law  states  that  cases 
of  disease  on  the  specified  list  of  diseases  dangerous  to  public  health  must 
be  reported  immediately,  but  as  the  time  allowed  physicians  and  others 
for  reporting  cases  is  not  specified,  there  is  every  reason  to  believe  that 
all  cases  are  not  reported  to  the  board  of  health.  Mortality  in  many 
transmissible  diseases  varies  widely,  but  the  mortality  in  certain  dis- 
eases bears  a  fairly  constant  relation  to  the  number  of  cases.  For 
example,  the  study  of  a  large  number  of  cases  of  typhoid  fever  in  cities 
has  fixed  the  case  mortality  at  10  to  12  percent  of  cases.  In  Springfield 
during  the  past  year  91  cases  and  20  deaths  from  typhoid  fever  were 
reported,  giving  an  exceptionally  high  case  mortality  of  24  percent. 
Calculating  the  probable  number  of  cases  on  the  average  case  mortal- 
ity above  stated,  there  were  in  Springfield  during  1913  from  165  to  200 
cases  of  typhoid  fever,  only  81*  or  40  to  50  percent  of  which  were  re- 
ported to  the  health  department.  If  we  may  accept  the  findings  of 
other  investigators  as  accurate  there  is  evident  need  for  more  thorough 
reporting  of  this  disease  at  least. 

More  Careful  Investigation  of  Typhoid  Cases  Needed 

The  81  cases  of  typhoid  fever  reported  in  1913  were  classified  by  the 
health  department  as  follows :  ^ 

11  cases  imported  (from  other  towns) 

27  cases  —  probably  out  of  town  infections,   were  away 

from  the  city  within  30  days  of  first  symptoms 
34  cases  —  source  untraced 
8  cases  —  on  one  milk  route 

The  health  department  record  of  typhoid  fever  cases  calls  for 
information  regarding  the  probable  source  of  the  disease,  but,  ciside  from 
the  report  which  is  obtained  by  the  sanitary  inspector,  the  records  do 
not  show  that  proper  investigation  of  these  cases  was  made.  For  ex- 
ample, the  fact  that  eight  cases  appeared  on  the  route  of  one  milk  dealer 
is  considered  by  the  health  department  as  a  coincidence,  and  accepted 

*  Total  number  of  cases  shown  in  health  department's  analysis  is  only  80,  al- 
though the  health  department's  reports  show  81  cases  during  the  year. 

15 


as  such.  It  is  an  accepted  fact,  however,  that  in  cities  with  a  uniformly 
good  water  supply  (such  as  Springfield  has),  probably  90  percent  of  cases 
are  due  to  infected  milk.  The  department  should  keep  currently  tabu- 
lations which  will  show  the  number  of  cases  charged  against  each  milk 
dealer;  and  the  investiga  ion  of  cases  should  include  a  thorough  study 
of  possible  sources  of  the  disease  in  milk,  both  at  the  producers  and  at 
the  retailers. 


Need  for  Investigation  of  Diphtheria  and  Scarlet  Fever 

Although  it  is  well  known  that  milk  is  frequently  responsible  for 
cases  of  diphtheria,  scarlet  fever,  and  tonsilitis,  the  health  department 
makes  little  effort  to  trace  the  sources  of  diphtheria  and  scarlet  fever 
beyond  recording  the  source  of  the  patient's  milk  supply.  Tabulation 
should  be  made  of  all  cases  of  diphtheria  and  scarlet  fever,  and  each 
case  should  be  charged  against  the  milk  supply  of  the  patient.  This 
does  not  mean  that  the  particular  milk  supply  is  necessarily  responsible. 
If  it  should  be  found  from  this  tabulation  that  a  certain  dealer  has  an 
undue  proportion  of  disease  charged  against  his  supply,  careful  investi- 
gation should  be  made  to  discover  the  reason  and  an  effort  made  to 
prevent  further  spread  of  the  disease  if  milk  is  found  to  be  the  source. 
It  is  of  no  value  simply  to  record  facts  regarding  disease  unless  those 
facts  are  used  for  prevention. 

Aids  to  More  Complete  Reporting  of  Disease 

There  are  probably  many  other  cases  of  disease  "  dangerous  to 
public  health  "  which  do  not  come  under  the  observation  of  a  physician. 
Such  cases  are  not  reported,  therefore,  unless  the  cooperation  of  all 
those  likely  to  come  in  contact  with  the  disease  is  secured.  Sanitary 
inspectors  in  making  their  rounds  of  inspection  frequently  visit  homes 
where  there  is  illness,  and  they  should  be  required  in  all  cases  to  ask 
"  Is  there  any  one  sick  in  the  house?  "  In  Pittsburgh  this  is  routine 
procedure,  and  many  cases  of  disease  not  otherwise  discovered  and  re- 
ported are  thus  brought  under  health  control.  School  nurses  should 
also  be  required  to  report  any  cases  of  illness  which  they  may  discover 
in  the  course  of  their  home  visiting.  Proprietors  of  hotels  and  lodging 
houses,  nurses  and  social  workers  connected  with  private  agencies,  super- 
intendents of  hospitals  and  institutions,  and  all  who,  by  the  nature  of 
their  work,  are  likely  to  come  in  contact  with  disease,  should  be  furnished 
with  report  blanks  and  urged  to  cooperate  with  the  health  department 
in  securing  complete  registration  of  disease. 

There  are  several  other  measures  for  improving  the  reporting  of 

16 


niANK  L.  KCLLY,  M.  O. 

transmissible  diseases  which  should  suggest  themselves  to  the  health 
physician  or  health  agent.     These  may  be  briefly  summarized  as  follows: 

1  —  Checking    hospital    records    against    register   of   dis- 

eases dangerous  to  public  health 

2  —  Periodic    visits    to    hospitals    to   discover   cases    not 

otherwise  reported,  particularly  tyhpoid  fever 

3  —  Checking  death  returns  in  order  to  discover  deaths 

from  diseases  dangerous  to  public  health  but  not 
previously  reported 

4  —  Wider  publicity  of  health  facts 

Registration  and  Control  of  Tuberculosis 

The  control  of  tuberculosis  is  at  present  in  the  hands  of  the  Tuber- 
culosis Association,  a  private  agency,  although  the  health  department  is 
required  to  keep  a  record  of  cases.  A  tuberculosis  dispensary  is  main- 
tained by  the  Tuberculosis  Association  under  the  approval  of  the  state 
board  of  health  as  required  by  law.  Most  cities  have  found  that  better 
control  of  tuberculosis  is  obtained  by  placing  all  responsibility  actually 
upon  the  health  department,  which  is  assumed  to  be  responsible  by  state 
and  local  authorities  for  registration  regardless  of  what  outside  agencies 
may  be  interested  in  the  work.  It  is  recommended,  therefore,  that  as 
soon  as  practicable  the  department  of  health  take  over  as  much  of  this 
work  as  is  practicable  with  the  facilities  at  hand.  A  number  of  anti- 
tuberculosis societies  in  other  cities  have  given  over  to  the  health  de- 
partment all  registration  and  administrative  control,  while  continuing 
their  outdoor  service  by  visiting  nurses.  So  long  as  the  health  depart- 
ment is  required  by  law  to  register  all  cases  of  tuberculosis  there  is  no 
need  for  detailed  registration  by  the  Tuberculosis  Association,  as  this 
means  simply  duplication. 

Tuberculosis  Register  Should  Be  Revised 

In  the  report  of  the  health  department  for  1913  the  statement  is 
found  that  95  percent  of  all  cases  of  tuberculosis  are  reported  to  the 
department.  This  statement  is  probably  inaccurate.  One  hundred  and 
twenty-five  cases  of  pulmonary  tuberculosis  were  reported  and  73  deaths. 
Competent  authorities  have  estimated  that  for  every  death  there  are 
at  least  five  living  cases.  On  this  basis  the  number  of  living  cases  in 
Springfield  may  be  estimated  as  365.  The  register  of  living  cases  of 
tuberculosis,  as  kept  in  the  health  department,  contains  the  records  of 
485  cases,  but  as  each  case  is  registered  on  a  separate  card  and  as  these 
cards  have  been  very  incompletely  filled  out,  the  record  has  little  value 
as  at  present  kept.     Many  of  the  485  cases  found  in  the  health  depart- 

17 


ment  register  were  reported  as  early  as  1905,  and  no  subsequent  data  as 
to  their  condition  or  residence  have  been  supplied. 

This  register  should  be  immediately  revised  from  the  records  of 
the  Tuberculosis  Association.  Unless  it  can  be  brought  up  to  date  and 
made  to  serve  some  useful  purpose  either  in  prevention  or  control  of 
this  disease,  it  is  simply  a  waste  of  time  and  money  to  keep  the  record. 
This  further  emphasizes  the  need  for  the  entire  responsibility  of  registra- 
tion, for  cooperation  between  the  health  department  and  the  Tubercu- 
losis Association  in  registration  of  cases  is  admittedly  not  as  good  as  it 
might  be. 


Placards  Should  Be  Understood  by  Laymen 

It  is  suggested  that  the  placard  used  in  anterior  poliomyelitis  be 
changed  to  read  "  infantile  paralysis,"  for  technical  medical  terms  mean 
little  to  the  average  layman. 


Quarantine,  Disinfection,  and  Quarantine  Release 

The  rules  of  the  state  board  of  health  regarding  quarantine,  disin- 
fection, and  quarantine  release  are  excellent,  and  so  far  as  can  be  deter- 
mined from  the  statement  of  the  health  agent,  they  are  well  carried  out. 
The  health  department  in  its  annual  report  for  1913  comments  upon  the 
fact  that  disinfection  is  of  doubtful  value  in  many  cases  formerly  con- 
sidered to  require  disinfection.  The  procedure  which  the  health  de- 
partment must  follow  is  however  fixed  by  law,  and  in  view  of  the  present 
opinion  of  laymen  as  to  the  necessity  for  disinfection,  changes  of  pro- 
cedure in  Springfield  may  well  wait  more  definite  knowledge  on  the 
subject. 


Better  Records  of  Disinfection  Needed 

If  we  are  to  come  to  any  definite  or  helpful  conclusions  regarding 
the  comparative  value  of  disinfection  procedure,  better  records  are 
needed.  Sanitary  inspectors  should  be  required  to  render  detailed  re- 
ports of  their  service  in  disinfection.  These  reports  should  show  the 
amount  and  kind  of  disinfectant  used,  time  spent  by  the  sanitary  in- 
spector, cubic  feet  of  space  fumigated,  etc.  It  is  of  little  value  to  know 
that  the  sanitary  inspector  fumigated  10  rooms  unless  we  know  how 
much  material  he  used,  the  cubic  contents  of  the  rooms  disinfected  or 
fumigated,  and  the  amount  of  time  spent.  The  cost  of  disinfection  is 
considerable.     If  the  benefit  derived  from  disinfection  as  now  practiced 

18 


is  not  an  adequate  return  for  money  expended,  the  health  department 
should  know  it  in  order  that  procedure  may  be  changed.  The  laboratory 
could  be  of  the  greatest  service  in  determining  the  comparative  value  of 
disinfectants  or  fumigants  used.  If  disinfection  is  incomplete,  it  is 
worthless.  Tests  should  therefore  be  made  to  determine  accurately 
whether  ordinary  room  disinfection  as  now  practised  really  disinfects. 


Laboratory  Service  a  Valuable  Aid  in  Prevention  of  Disease 

In  furnishing  physicians  with  facilities  for  proper  diagnosis  of 
disease,  in  perfecting  quarantine  regulations,  in  improving  the  reporting 
of  disease,  and  in  the  analysis  of  milk  and  other  foods,  all  extremely 
important  factors  in  health  control,  the  laboratory  is  an  indispensable 
part  of  the  city's  health  service. 

It  is  unfortunate  that  no  facilities  were  provided  in  the  new  munici- 
pal building  for  laboratory  service.  The  present  quarters  are  alto- 
gether inadequate,  and  should  be  abandoned  as  soon  as  possible.  Good 
light,  plenty  of  room,  proper  plumbing  facilities  and  adequate  equip- 
ment, none  of  which  the  laboratory  now  has,  are  essential  to  efficient 
laboratory  service.  In  the  annual  report  of  the  health  department  for 
1913  the  attention  of  the  municipal  group  commission  was  called  to  the 
need  for  providing  accommodations  for  laboratory  purposes  in  the  mun- 
icipal building.  As  yet  this  has  not  been  done,  but  it  is  recommended 
that  steps  be  immediately  taken  to  bring  it  about.  The  rental  of  the 
present  quarters  will  amount  to  $600  during  the  coming  year.  This 
sum  would  go  far  toward  providing  the  needed  facilities  in  the  municipal 
building. 


Laboratory  Service  Should  Be  Extended 

According  to  the  report  of  the  department  for  1913  the  bacteriol- 
ogist made  119  examinations  of  blood  from  typhoid  patients,  examined 
299  specimens  of  sputum  of  tuberculosis  cases,  and  1279  diphtheria 
cultures;  a  total  of  1697  examinations  during  the  year,  or  a  daily  aver- 
age of  from  five  to  six  examinations.  This  means  either  that  physicians 
are  not  taking  advantage  of  the  laboratory  as  they  should,  or  that  the 
laboratory  is  not  extending  its  service  to  the  limit. 

The  bacteriological  laboratory  of  the  city  of  Springfield  should 
be  rendering  ten  times  as  much  service  to  the  city.  Some  of  the  ways 
in  which  the  laboratory  may  further  assist  in  protecting  the  health  of 
citizens  are: 

19 


Examination  of  specimens  for  the  detection  of  venereal 
disease,  including  blood  tests  for  syphilis 

Examination  of  specimens  for  the  detection  of  epidemic 
cerebro  spinal  meningitis 

Examination  of  specimens  from  eyes  of  school  children, 
(14  cases  of  ophthalmia  neonatorum  and  67  cases  of 
"  inflamed  eyes  "  were  reported  in  1913,  but  there  is  no 
evidence  that  diagnosis  was  made  by  laboratory  exami- 
nations) 

Provisions  of  facilities  for  furnishing  typhoid  immuniza- 
tion to  those  who  may  wish  it 

Examination  of  stools  for  the  detection  of  typhoid  carriers 

Bacteriological  and  chemical  tests  of  disinfectants  and 
disinfection  procedure 

Research  to  discover  bacterial  or  other  contamination  of 
foods,  as  exposed  bakestuffs,  fruits,  candies,  etc. 

Research  to  discover  contamination  of  milk  by  tubercle 
bacilli 


Laboratory  Reports  Should  Not  Be  Made  on  Post  Cards 

The  laboratory  has  proved  to  be  of  great  service  in  improving  the 
reporting  of  certain  diseases.  This  service  is  given  free  of  charge  to 
physicians.  Diagnosis  of  diphtheria,  tuberculosis  and  typhoid  fever 
may  be  made  certain  by  laboratory  examination  of  specimens.  The 
physician  is  promptly  notified  of  the  result  of  the  laboratory  examina- 
tion, and  when  specimens  are  found  to  be  "  positive  "  the  health  depart- 
ment is  also  notified.  Physicians  are  notified  of  the  findings  of  the  lab- 
oratory on  post  cards,  a  different  kind  of  post  card  being  used  for  each 
disease.  It  is  recommended  that  physicians  be  notified  on  a  form  which 
may  be  mailed  in  a  sealed  envelope,  or  if  post  cards  are  used,  that  code 
numbers  be  used  instead  of  patients'  names.  There  is  no  reason  why 
the  names  of  patients  should  be  disclosed  on  post  cards;  and  physi- 
cians will  be  more  ready  to  cooperate  with  the  department  in  reporting 
disease  if  they  are  assured  that  unnecessary  publicity  will  not  be  given 
to  the  names  of  their  patients.  Publicity  of  health  facts  is  desirable, 
but  this  kind  of  publicity  retards  cooperation  by  physicians  which  is 
necessary  if  the  laboratory  is  to  be  serviceable.  A  physician  will  natur- 
ally hesitate  to  send  a  specimen  of  sputum  from  his  patient  with  tuber- 
culosis when  he  knows  that  the  official  notification  of  his  patient's  name 
and  the  laboratory's  findings  will  be  returned  on  a  post  card  which  any 
one  may  read.  |j||^ 

It  is  also  recommended  that  a  single  notification  form  be  used  for 
all  notices  to  physicians  regarding  laboratory  findings.  The  cost  of 
printing  these  forms  may  be  reduced  fully  one-half  in  this  way. 

20 


PROTECTION  OF  THE  HEALTH  OF  CHILDREN 

Birth  and  Death  Records  Important 

The  protection  of  child  health  should  begin  with  birth,  and  in  any 
child  welfare  campaign,  careful  study  and  analysis  of  birth  returns  is 
fundamental.  The  age  of  parents,  their  nationality,  the  place  of  birth 
by  wards  or  in  institutions,  circumstances  attending  birth,  by  whom 
attended,  whether  physician  or  midwife,  are  all  important  to  the  health 
officer.  The  meagre  information  regarding  births,  which  is  furnished 
by  the  city  clerk  to  health  officials  in  strict  accordance  with  the  law,  is 
useless  as  a  basis  for  effective  control  of  conditions  attendant  at  birth. 
The  same  is  true  of  death  returns.  The  health  officer  should  analyze 
the  returns  of  births  and  deaths,  particularly  of  infants,  and  the  analysis 
could  not  fail  to  point  out  where  work  is  needed.  Closer  cooperation 
between  the  city  clerk  who  receives  the  returns  of  births  and  deaths  and 
the  health  department  can  be  secured  with  little  effort.  The  fact  that 
the  state  law  prescribes  the  amount  and  kind  of  information  which  the 
city  clerk  must  render  to  the  health  department  is  no  reason  why  all 
the  information  needed  should  not  be  obtained. 

Low  Infant  Mortality  Rate 

Springfield  is  to  be  congratulated  on  its  low  infant  mortality  rate. 
Out  of  3105  births  during  1913,  exclusive  of  still  births,  there  were  only 
295  deaths  during  the  first  year  of  life.  This  gives  Springfield  an  infant 
mortality  rate  of  95  per  1000  births,  —  a  lower  infant  mortality  rate 
than  any  other  city  of  its  size  in  the  country  of  which  there  is  accurate 
record.  Two  factors  are  largely  responsible  for  this  low  infant  mor- 
tality rate.  Springfield  has  a  remarkably  good  milk  supply  largely  due 
to  the  regulations  of  the  health  department  governing  the  production 
and  sale  of  milk  and  the  efficient  service  of  the  milk  inspectors.  The 
Baby  Feeding  Association,  a  private  organization,  through  its  visiting 
nurses,  has  endeavored  to  educate  mothers  in  the  proper  care  of  their 
children,  in  infant  feeding,  and  in  the  general  child  welfare  program. 

Extension  of  Child  Welfare  Service 

Protection  and  preservation  of  child  health  is  the  most  fertile  of  all 
health  fields,  and  Springfield  has  unquestionably  made  a  good  begin- 
ning. Several  features  of  an  efficient  child  welfare  program  have  been 
neglected,  although  not  wholly  from  failure  on  the  part  of  the  health 
department  to  see  their  need.  In  the  report  of  the  health  department 
for  1913  there  is  frequent  reference  to  the  need  for  more  extended  work 
along  this  line.     Among  some  of  the  needs  of  the  Springfield  health  de- 

21 


partment  in  carrying  on  its  campaign  for  the  protection  of  child  health 
are  the  following: 

The  appointment  of  a  child  welfare  nurse 
Registration  and  supervision  of  midwives 
More  adequate  supervision  of  day  nurseries,  infant  board- 
ing houses,  and  children  in  institutions 

Child  Welfare  Nurse  Recommended 

The  health  department  requested  that  funds  be  appropriated  for 
the  service  of  a  child  welfare  nurse  during  the  coming  year.  It  is  to  be 
regretted  that  this  request  was  not  allowed.  The  child  welfare  nurse 
plays  a  most  important  role  in  every  adequate  health  program.  In- 
struction of  mothers  in  the  care  of  themselves  during  pregnancy  and  after- 
wards and  of  their  babies;  the  investigation  of  births  attended  by  mid- 
wives  and  the  supervision  of  midwives'  methods  and  equipment;  in- 
vestigation of  day  nurseries,  infant  boarding  houses,  and  conditions 
under  which  children  are  cared  for  in  institutions;  securing  cooperation 
between  outside  agencies,  the  pauper  department,  and  the  health  de- 
partment; all  are  essentials  of  a  well  organized  program.  It  is  recom- 
mended, therefore,  that  such  a  nurse  be  appointed.  In  view  of  the 
fact  that  the  services  of  a  social  nurse  have  been  recommended  in  the 
pauper  department,  it  is  suggested  that  for  the  present  at  least,  the  ser- 
vice required  by  the  health  department  and  that  required  by  the  pauper 
department  be  performed  by  the  same  person,  who  may  be  called  the 
"  city  nurse."  As  the  need  for  extension  of  this  kind  of  health  and  social 
service  is  demonstrated,  it  will  doubtless  be  necessary  to  employ  separate 
nurses  for  these  two  departments. 

Supervision  of  Midwives  Needed 

Midwives  are  entirely  unsupervised  in  Springfield.  As  no  regis- 
tration of  midwives  is  required,  it  is  impossible  to  say  how  many  there 
are  in  the  city.  Experience  in  other  cities  leads  to  the  belief  that  at 
least  10  percent  of  all  babies  are  attended  at  birth  by  midwives.  In 
some  cities  where  there  is  a  large  percentage  of  foreign  population,  the 
percentage  is  much  higher.  To  how  great  an  extent  registration  and 
supervision  of  midwives  would  reduce  infant  mortality  in  Springfield  is 
uncertain.  The  records  of  infant  mortality  and  of  infant  sickness  are, 
however,  very  suggestive.  Fifty-five  children  died  of  premature  birth 
and  it  is  more  than  probable  that  many  of  them  were  attended  by  mid- 
wives.  Fourteen  cases  of  ophthalmia  neonatorum  (a  specific  disease 
causing  blindness  in  babies)  were  reported  in  1913,  and  it  is  also  more 

22 


than  probable  that  a  number  of  those  may  be  directly  traced  to  im- 
proper care  of  the  babies'  eyes  at  birth.  It  is  the  experience  of  other 
cities  that  midwives,  unless  properly  supervised  and  instructed,  com- 
monly neglect  this  important  duty.  The  records  of  the  health  depart- 
ment show  that,  (except  for  1913)  there  has  been  a  steady  increase  in 
the  number  of  cases  of  ophthalmia  neonatorum  in  the  past  six  years. 

Year  Cases  Reported 

1908 1 

1909 7 

1910 12 

1911 15 

1912 18 

1913 14 

In  addition  to  the  14  cases  reported  as  ophthalmia  neonatorum, 
there  were  67  cases  of  inflamed  eyes.  The  records  of  the  laboratory  do 
not  show  any  examination  of  eye  secretions  to  determine  whether  any 
of  these  cases  were  ophthalmia  neonatorum.  Without  adequate  labo- 
ratory examinations,  accurate  diagnosis  is  impossible. 

Preventive  Campaign  Needed 

The  state  board  of  health  furnishes  the  health  department  with 
silver  nitrate  outfits,  which  are  distributed  to  physicians  and  nurses  as 
requested.  The  proper  application  of  this  remedy  is  a  positive  preven- 
tive of  the  disease.  The  continued  presence  of  this  disease  in  Springfield 
indicates  lack  of  adequate  preventive  measures.  Publicity  must  be 
widespread,  not  only  among  laymen  but  among  physicians  and  mid- 
wives.  Neglect  to  observe  proper  precautions,  even  among  families  in 
the  very  best  circumstances,  is  often  disastrous. 

Supervision   of    Institutions   for    Children 

A  card  index  was  found  in  which  there  was  a  record  of  17  lodging 
houses,  four  infant  boarding  houses,  and  one  lying-in  hospital  (at  the 
almshouse).  The  board  of  health  requires  that  these  institutions  be 
inspected  and  approved  by  the  board,  but  there  is  no  regular  reinspec- 
tion  to  determine  the  conditions  under  which  they  are  operated.  The 
cards  give  no  information  regarding  infant  boarding  houses  other  than 
their  location,  the  date  of  their  inspection  and  approval  by  the  board, 
and  the  number  of  children  which  they  are  allowed  to  care  for.  Of  the 
four  infant  boarding  houses  registered  one  was  inspected  and  approved 
in  April,  1913,  one  in  December,  1913,  and  two  in  September,  1913. 
There  is  no  evidence  as  to  subsequent  visits.  It  is  recommended  that 
these  institutions  be  periodically  visited  at  least  once  each  month,  and 
that  complete  and  accurate  registration  be  made  of  conditions  found. 

23 


Infant  Mortality  Charts  Would  Be  Helpful 

Charts  should  be  made  showing  where  infant  mortality  is  highest 
and  where  lowest.  Such  charts  would  show  immediately  where  work 
is  needed.  Just  as  the  health  officer  finds  it  valuable  to  have  charts 
showing  the  prevalence  of  contagious  disease  and  pointing  out  need  for 
special  investigation,  so  charts  of  infant  mortality  would  point  out  need 
for  special  investigation  along  definite  preventive  lines.  The  report 
of  the  department  for  1913  shows  all  these  facts,  but  apparently  little 
use  is  made  of  them  except  as  they  are  used  for  the  annual  report. 

Duties  of  Medical  Inspectors 

There  are  thirteen  medical  inspectors  employed  by  the  board  pi 
health  at  salaries  of  $50  per  month  each  for  a  ten-month  period.  Physi- 
cians are  required  to  visits  schools  twice  each  week  at  9.30  a.  m.,  and  to 
devote  as  much  time  as  may  be  necessary  to  the  work.  The  rules  state 
that  they  shall : 

1  —  Inspect  all  children  detained  by  the  room  teacher  or  nurse 

on  account  of  suspected  contagious  disease 

2  —  Inspect  all  children  returning  to  school  after  an  absence 

beyond  two  days 

3  —  Inspect  children  who  are  ill  and  sent  to  the  inspector  for 

diagnosis  and  advice  by  the  room  teacher  or  nurse.  Also 
reinspection  of  children  previously  ordered  under  treat- 
ment 

4  —  Make  special  daily  inspection  of  children  in  any  school 

room  who  have  been  exposed  to  diphtheria  or  scarlet  fever 
by  other  pupils  in  the  room  taken  sick  with  the  disease 
mentioned 

5  —  Make  physical  examinations  of  all  children  in  the  public 

schools  each  year,  assisted  by  the  teacher  and  the  nurse 

6  —  Make  special  insjjection  of  the  ventilation  and  sanitary 

conditions  of  school  buildings  at  least  once  a  month 

Records  of  Service  Performed  Inadequate 

Physicians  are  required  to  make  weekly  reports  of  their  inspections 
and  examinations  on  special  forms,  one  form  being  provided  for  physical 
examinations,  and  another  for  inspection  only.  On  the  form  which  re- 
quires report  of  physical  examinations,  the  physician  is  required  to  state 
how  much  time  was  spent  in  making  the  examination.  This  is  the  only 
time  record  in  use  and  it  has  been  used  only  during  the  present  school 
year.  Examinations  of  these  records  show  that  they  are  improperly 
made  out  and  inadequately  supervised  by  the  health  agent  or  by  the 
board.  The  following  instances  show  the  need  for  improved  reports 
on  the  part  of  medical  inspectors  and  more  careful  supervision  of  these 
reports  as  they  are  rendered. 

24 


One  inspector  sent  in  12  reports,  all  dated  December  2 2d. 
Each  report  gave  the  result  of  examinations  in  one  school 
room,  and  in  each  case  the  amount  of  time  spent  by  the 
inspector  in  a  room  was  two  and  a  half  hours.  It  was  of 
course  impossible  for  the  inspector  to  spend  two  and  a 
half  hours  in  each  of  12  rooms  on  December  2 2d. 

Another  inspector  sent  in  three  reports  on  January  13th, 
stating  that  110  pupils  had  been  examined  in  three  dif- 
ferent rooms  in  four  and  one-half  hours,  or  at  the  rate  of 
24  per  hour  or  one  every  two  and  one-half  minutes,  —  a 
physical  impossibility  if  thorough  examinations  are 
made 

Still  another  inspector  sent  in  three  reports  dated  Febru- 
ary sixth,  and  in  the  three  rooms  visited  spent  six  and 
three-quarters  hours  in  physical  examination,  —  in 
all  probability  an  incorrect  statement,  as  the  school  day 
is  not  six  and  three-quarters  hours  long 

In  one  instance  an  inspector  reported  that  on  December 
17th  he  visited  two  rooms  and  examined  75  pupils  in 
six  and  one-half  hours 

In  another  instance  an  inspector  reported  that  he  made  in 
one  week  325  physical  examinations  in  15^  hours  or 
at  the  rate  of  22  examinations  per  hour 

Notwithstanding  the  fact  that  teachers  make  examinations  of  eyes 
and  ears,  it  is  to  be  doubted  whether  any  physician  can  make  22  to  24 
thorough  physical  examinations  in  an  hour.  The  best  authorities  place 
6  to  10  examinations  per  hour  as  the  limit  of  efficiency.  In  the  cir- 
cular of  instructions  issued  by  the  health  department  the  statement 
appears,  "  The  room  teacher  and  nurse  are  expected  to  assist  the  inspec- 
tor in  such  measures  as  may  be  necessary  for  the  early  completion  of  the 
work.     With  such  assistance,  10  to  12  pupils  can  be  examined  hourly." 

Time  Records  Valueless 

It  was  evidently  intended  that  the  records  of  physical  examination 
should  show  accurately  the  time  spent  by  physicians  in  making  physical 
examinations.  If  they  had  been  kept  accurately,  they  would  un- 
doubtedly have  furnished  valuable  evidence  as  to  the  efficiency  of  in- 
spectors and  their  work.     As  now  kept  they  are  worthless. 

Inspectors  evidently  thought  that  the  dates  required  by  the  reports 
were  the  dates  on  which  they  were  sent  to  the  department,  although  the 
record  form  states  "  This  blank  is  to  be  made  up  from  individual  records 
and  returned  to  the  office  promptly  on  completion  of  the  examination  of 
pupils  in  each  room,  i.e.  with  weekly  reports."  If  the  record  does  not 
give  the  date  on  which  the  examinations  were  made,  no  information  as 
to  the  actual  amount  of  time  spent  on  any  one  day  in  physical  examina- 
tions is  available. 

25 


Need  for  More  Thorough  Physical  Examinations 

According  to  the  reports  of  the  inspectors,  out  of  a  total  of  13,589 
examinations  made  by  medical  inspectors  in  the  schools,  only  106  cases 
of  chronic  hypertrophied  tonsils,  42  cases  of  adenoids,  and  14  cases  of 
defective  breathing  were  discovered.  This  gives  a  total  of  162  cases 
of  hypertrophied  tonsils,  adenoids,  and  defective  breathing,  or  approx- 
imately 1.2  percent  of  all  pupils  examined.  Either  the  percentage  of 
defects  of  this  kind  is  remarkably  low  or  examinations  are  not  carefully 
made.  A  comparison  of  like  findings  in  other  cities  shows  that  the 
percentage  of  cases  of  adenoids,  tonsils,  and  defective  breathing  varies 
widely  from  as  high  as  20  to  25  percent  among  children  in  lower  grades 
to  from  5  to  10  percent  among  children  in  higher  grades. 

In  a  cooperative  study  made  by  the  bureau  of  child  hygiene  of 
the  New  York  health  department  and  the  Bureau  of  Municipal  Research, 
it  was  found  that  1442  children  in  three  New  York  schools  showed  the 
following  percentage  of  physical  defects  due  to  hypertrophied  tonsils  and 
defective  nasal  breathing: 

Defective  nasal  breathing 59  percent 

Hypertrophied  tonsils 39  percent 

On  the  basis  of  a  40  week  school  year,  two  days  per  week,  13  physi- 
cians examining  13,589  children  would  be  required  to  examine  about 
13  children  at  each  school  visit.  In  view  of  the  fact  that  under  the  state 
law  examinations  for  sight  and  hearing  are  made  by  teachers,  the  thor- 
ough examination  of  13  children  should  not  require  much  more  than  one 
hour.  There  is  therefore  no  reason  why  any  physician  should  find  it 
necessary  to  make  as  many  as  22  examinations  per  hour.  Properly 
distributed,  physical  examinations  could  be  easily  made  during  the 
year.  It  is  therefore  unnecessary  that  the  physicians  should  work  at 
such  a  rapid  rate  for  only  part  of  the  year.  Physical  examinations 
made  less  rapidly  would  probably  be  made  more  efficiently. 

Records  of  Defects  of  Teeth  Incomplete 

In  the  report  for  1913  no  figures  are  given  as  to  the  number  of 
cases  of  defective  teeth  found,  although  in  the  report  for  the  preceding 
year  the  discovery  of  555  cases  of  defective  teeth  was  reported.  The 
remedying  of  defective  conditions  of  teeth  is  one  of  the  most  important 
functions  of  medical  inspection,  and  many  cities  have  established  free 
dental  clinics  for  this  purpose.  It  is  recommended  that  the  same  pro- 
cedure be  followed  in  caring  for  defective  teeth  as  in  other  defects,  and 
that  records  be  kept  which  will  show  whether  defects  of  teeth  are  being 

26 


remedied.  Nurses  should  make  home  visits  when  necessary  to  give 
dental  treatment,  and  the  results  of  their  work  should  be  as  clearly  stated 
as  the  results  of  home  visits  for  other  purposes. 


School  Dental  Clinic  Needed 

The  school  dental  clinic  has  proved  to  be  a  most  effective  part  of 
the  medical  inspection  service.  A  school  dental  clinic  may  be  equipped 
at  an  initial  cost  of  $300  to  $400.  Without  it,  the  remedying  of  defects 
of  teeth  is  not  easily  obtained.  It  is  probable  that  a  dentist  could  be 
secured  at  a  small  salary  to  give  one  or  two  mornings  per  week  to  this 
work.  The  city  of  Hoboken  has  found  the  dental  clinic  to  be  a  most 
satisfactory  aid  in  improving  the  health  of  its  school  children;  in  fact, 
the  benefit  derived  has  been  so  great  that  Hoboken  has  employed  a 
school  dentist  at  $1500  a  year  to  conduct  dental  clinics  five  days  a  week, 
and  it  is  not  uncommon  to  see  25  or  30  children  at  the  clinic  waiting  to  be 
treated.  New  York  City  has  a  well  developed  dental  clinic  system,  and 
Dr.  Josephine  S.  Baker,  director  of  the  bureau  of  child  hygiene  of  the 
New  York  health  department,  regards  the  dental  clinics  as  indispensable. 
Approximately  75  to  80  percent  of  school  children  have  defective  teeth. 
Springfield  should  consider  the  advisability  of  providing  a  dental  clinic 
during  the  coming  year. 


School  Medical  Clinic 

The  school  medical  clinic  is  also  an  advanced  step  in  health  control. 
Hoboken's  medical  clinic  also  may  be  mentioned  here  as  a  particularly 
excellent  one.  The  initial  cost  of  equipping  this  medical  clinic,  which  is 
in  the  high  school  building,  was  approximately  $1000.  Hoboken  be- 
lieves that  this  was  money  well  spent,  for  many  defects  of  children  which 
otherwise  might  go  unattended  are  promptly  taken  care  of  in  the  school 
clinic.  The  establishment  of  a  school  clinic  may  also  be  offered  as  a 
suggestion  for  improving  Springfield's  health  service.  The  object  of 
medical  inspection  and  supervision  is  not  merely  to  find  physical  de- 
fects, but  also  to  see  that  these  defects  are  treated.  The  loss  of  time  by 
pupils  on  account  of  physical  defects  which  prevent  them  from  striking 
a  normal  pace  in  school  work,  the  loss  of  time  by  teachers  in  trying  to 
hurry  along  those  who  are  backward  by  reason  of  physical  disability, 
the  loss  to  the  individual  in  health  and  the  consequent  cost  to  the  com- 
munity are  factors  which  should  be  considered  in  determining  whether 
the  city  can  afford  the  expense  of  these  improvements  in  medical  in- 
spection. 

27 


Visits  Should  Be  Made  Daily 

For  the  detection  of  contagious  diseases  and  improved  supervision 
of  the  welfare  of  children,  it  is  recommended  that  inspectors  make  school 
visits  daily  instead  of  twice  a  week.  Two  hours  a  day  for  five  days  a 
week  in  medical  inspection  would  mean  approximately  40  hours  a 
month.  At  this  rate  the  physician  would  be  paid  at  the  rate  of  $1.25 
per  hour  or  $8.75  per  day  of  seven  hours.  This  would  mean  a  probable 
increase  of  four  hours  a  week  in  service. 

Duties  of  School  Nurses 

Two  nurses  are  employed  at  $65  per  month  each,  and  provision  has 
been  made  for  an  additional  nurse  at  a  like  salary.  The  instructions  to 
nurses  state  that  they  are  required  to  make  visits  to  the  homes  of  chil- 
dren: 

1  —  Who  have  been  excluded  from  school 

2  —  Who  are  not  receiving  requested  treatment  for  para- 

sitic conditions 

3  —  Without  medical  care  who  should  receive  such  atten- 

tion, but  only   after  notification   of  the   need    for 
treatment  has  been  sent  to  the  parents 

4  —  Having  eye,  ear,  or  throat  conditions  which  are  neg- 

lected by  parents 

According  to  the  report  of  medical  inspectors  for  1913,  cases  were 
referred  to  nurses  as  follows: 

Skin  diseases 116 

Parasitic  affections 107 

Enlarged  tonsils  and  adenoids 137 

Defective  eyesight 100 

Miscellaneous 94 

Total 554 

Out  of  the  total  554  cases  referred  to  nurses,  446  or  80  percent  were 
reported  as  "relieved."  Fifty-eight  percent  of  100  cases  having  defective 
eyesight  were  fitted  with  glasses,  and  31  or  22  percent  of  137  cases  of 
enlarged  tonsils  and  adenoids  were  cured  by  operation.  This  is  a  praise- 
worthy record  so  far  as  treatment  is  concerned.  In  all,  the  nurses  made 
only  1199  home  visits.  On  the  basis  of  a  200-day  school  year,  they  aver- 
aged only  three  home  visits  per  day.  The  nurses'  most  valuable  ser- 
vice in  the  program  of  medical  supervision  is  in  home  visiting.  In  view 
of  the  amount  of  work  which  physicians  found  for  nurses  to  do  according 
to  the  records  of  1913,  it  is  not  clear  why  an  additional  nurse  should 

28 


"«««  I.  wiir.  m.  o. 


have  been  deemed  necessary.  One  visiting  nurse,  according  to  the  ex- 
perience of  other  cities,  should  be  able  to  make  at  least  four  home  visits 
per  hour,  provided  she  arranges  her  home  visits  properly.  In  view  of 
these  facts  it  is  believed  that  more  home  visits  should  be  made  by  nurses. 
There  are  probably  many  more  cases  than  those  referred  to  nurses, 
according  to  the  record,  which  need  the  nurses'  attention  and  more 
thorough  examinations  on  the  part  of  the  physicians  may  demonstrate 
the  need  for  an  increased  number  of  nurses. 


Nurses  Should  Render  Time  Reports 

According  to  the  instructions  of  the  department  as  printed  in  cir- 
cular form,  nurses  are  required  to  make  daily  records  of  work  performed, 
and  weekly  reports  are  to  be  sent  to  the  health  department.  This  pro- 
cedure is  not  followed.  Monthly  reports  only  are  rendered,  and  these 
give  merely  a  summary  of  cases  referred  to  the  nurse  and  action  taken 
upon  them.  It  is  recommended  that  nurses  be  required  to  render  daily 
reports  of  service  with  a  statement  of  the  time  spent  in  each  line  of  duty. 
Experience  in  examining  the  work  of  school  nurses  in  other  cities  dem- 
onstrates that  little  attention  is  paid  to  the  arrangement  of  schedules 
for  home  visits  with  the  idea  of  saving  time  and  increasing  efficiency. 
Daily  reports  of  nurses  showing  how  time  was  spent  in  schools,  where 
visits  were  made,  and  the  time  required  to  make  them,  would  be  invalu- 
able in  determining  how  far  the  nursing  staff  is  able  to  cope  with  the 
work  and  whether  added  service  is  needed. 

Yearly  Sanitary  Survey  of  Schools  Recommended 

The  weekly  reports  of  inspections  call  for  information  as  to  the 
condition  of  sanitaries  and  the  adequacy  of  ventilation.  This  informa- 
tion is  regularly  furnished  each  month  as  required,  but  as  the  reports 
require  the  inspector  to  state  merely  whether  conditions  are  good,  fair, 
or  bad,  they  convey  little  information  as  to  conditions  actually  exist- 
ing. Springfield  has  reason  to  feel  proud  of  its  schools.  It  is  therefore 
incumbent  upon  the  community  to  give  proper  attention  to  school  sani- 
tation. It  is  recommended  that  in  addition  to  the  monthly  inspection 
of  sanitaries  and  of  ventilation  physicians  make  an  annual  survey  of 
sanitary  conditions  of  the  schools  under  their  charge  and  furnish  a  com- 
plete and  detailed  report  of  the  matter  to  the  school  department,  with 
recommendations  regarding  lighting,  ventilation,  cleaning  of  floors, 
toilets,  drinking  and  washing  facilities,  cloak  rooms,  fire  protection, 
etc.  Such  a  report  would  be  of  the  greatest  value  to  the  school  com- 
mittee in  bringing  all  school  buildings  up  to  proper  sanitary  standards. 

29 


Surveys  should  then  be  made  at  the  close  of  each  school  year  in  order 
that  necessary  improvements  may  be  made  before  the  beginning  of  the 
next  school  year. 

Salaries  of  School  Physicians  Ample 

The  city  of  Springfield  pays  medical  inspectors  at  the  rate  of  $50 
per  month  for  10  months'  service.  As  physicians  are  not  required  to 
furnish  records  of  service  performed,  except  as  to  the  time  spent  in 
making  physical  examinations,  it  is  impossible  to  say  how  much  time 
was  really  spent  by  inspectors  in  school  service.  From  a  study  of  such 
records  as  are  available,  it  is  estimated  that  inspectors  average  about  two 
and  one-half  hours  to  three  hours  per  day  of  five  to  six  hours  per  week. 
On  this  basis  they  receive  $2  to  $2.50  per  hour  or  at  the  rate  of  $14  to 
$17.50  per  day  of  seven  hours.  This  is  a  very  ample  provision.  The 
fact  that  officials  who  are  responsible  for  requesting  and  granting  sal- 
aries and  salary  increases  do  not  have  this  information,  makes  it  impos- 
sible for  them  to  determine  whether  salaries  or  salary  increases  are 
proper. 

Approved  Record  Forms  Recommended 

Both  physicians  and  nurses  should  be  required  to  render  daily 
reports  of  service  rendered  and  time  spent  on  duty.  Instead  of  two 
separate  weekly  reports  of  inspections  made  and  physical  examinations 
given,  one  report  of  all  work  performed,  rendered  after  each  school  visit, 
should  suffice.  This  would  simplify  reporting  and  reduce  printing  cost. 
The  physical  record  card  of  the  pupil  which  is  kept  in  the  school  by  the 
teacher  should  be  revised  so  as  to  show  not  only  physical  examinations 
made  but  inspections,  illness  from  contagious  disease  or  other  diseases, 
first  aid  given,  results  of  nurses,  efforts  to  secure  treatment,  and  in  short 
all  that  takes  place  with  reference  to  the  child's  health.  It  would  com- 
bine in  one  record  all  the  information  given  on  several  records  and  fur- 
nish a  valuable  guide  to  physician,  nurse,  and  teacher.  Cards  for  this 
purpose  have  been  devised  by  Dr.  Louis  W.  Rapeer  of  the  teachers' 
training  school  of  New  York  University,  and  may  be  taken  as  a  sample 
of  a  record  which  may  be  revised  to  suit  the  particular  needs  of  any  city. 
Anything  which  may  be  done  to  reduce  the  amount  of  clerical  work 
required  of  physicians,  nurses,  and  teachers  should  commend  itself  to 
any  one  with  experience  in  medical  inspection. 


30 


PROTECTION  OF  FOOD  SUPPLY 

Health  Department  Hampered  by  State  Act 

The  health  department  is  hampered  in  its  efforts  to  control  the  pro- 
duction and  sale  of  foods  by  a  state  law  which  reads:  "  Boards  of  health 
of  cities  and  towns  may  make  and  enforce  reasonable  rules  and  regula- 
tions, subject  to  the  approval  of  the  state  board  of  health,  as  to  the 
conditions  under  which  all  articles  of  food  may  be  kept  for  sale  or  ex- 
posed for  sale  in  order  to  prevent  contamination  thereof  and  injury 
to  the  public  health.  Before  the  board  of  health  of  any  city  or  town  sub- 
mits such  rules  and  regulations  to  the  state  board  of  health  for  approval 
it  shall  hold  a  public  hearing  thereon,  of  which  notice  shall  be  given  by 
publication  for  two  successive  weeks,  the  first  publication  to  be  at  least 
two  weeks  prior  to  the  date  of  the  hearing,  in  a  newspaper  published  in 
the  county  in  which  such  city  or  town  is  located.  Any  person  affected 
by  such  rules  and  regulations  in  the  form  in  which  they  are  presented 
to  the  state  board  of  health  for  approval,  may  appeal  to  the  said  board 
for  a  further  hearing  and  said  board  shall  not  grant  its  approval  to  rules 
and  regulations  concerning  which  such  appeal  has  been  taken  until  it 
has  held  a  public  hearing  thereon,  advertised  in  the  manner  specified 
above  in  this  section  with  reference  to  hearings  before  boards  of  health 
in  cities  and  towns." 

The  result  of  this  act  is  to  make  it  extremely  difficult  for  local  boards 
of  health  to  pass  regulations  to  protect  the  food  supply.  In  few  states 
is  the  right  of  the  local  boards  of  health  to  protect  the  health  of  its 
citizens  hampered  in  this  way,  and  yet  it  is  rare  indeed  that  the  individual 
affected  by  the  regulations  is  injured.  It  is  evident,  however,  that  the 
local  health  department  can  make  regulations  even  though  the  sanction 
of  the  state  board  is  necessary  and  the  amount  of  red  tape  which  must  be 
unwound  is  considerable.  The  board  of  health  has  shown  too  great 
reluctance  to  make  such  regulations  except  those  governing  sanitation 
in  bakeries  and  the  production  and  sale  of  milk. 


Inspector  of  Meats,  Provisions,  and  Slaughtering 

The  inspector  of  meats,  provisions,  and  slaughtering  visits  the  vari- 
ous food  establishments  and  inspects  food  products  according  to  the 
laws  which  the  state  has  laid  down  regarding  the  methods  of  handling 
and  selling  food.  These  laws  are  intended  to  be  supplemented  by  local 
regulations,  but  except  for  regulations  governing  bakeries  and  the  pro- 
duction and  handling  of  milk,  the  board  of  health  has  paid  little  atten- 
tion to  food  control. 

31 


The  report  of  the  inspector  of  meats,  provisions,  and  slaughtering 
shows  that  9662  wholesale  and  retail  stores  of  all  kinds  were  inspected 
in  1913.  This  record  is  a  quantity  record  only.  No  records  are  kept 
which  will  show  the  location  of  the  places  inspected,  what  conditions 
were  found,  what  improvements  recommended,  what  improvements 
were  made,  or  how  much  time  was  actually  spent  on  duty.  It  is  absurd 
to  send  an  inspector  out  on  hit-or-miss  inspection  of  this  kind  without 
any  check  whatever  upon  his  work,  except  a  summary  of  places  visited. 

Improved  Records  Needed 

Files  should  be  kept  in  which  each  store  or  business  inspected  may 
be  separately  registered  on  a  card.  This  card  should  contain  all  the 
information  required  regarding  the  sanitary  conditions  of  the  store, 
character  of  food  sold,  findings  of  inspector,  condemnation,  prosecu- 
tion, etc.  A  special  tickler  file  should  be  kept  of  stores  which  require 
frequent  inspection.  It  would  not  be  necessary  for  the  inspector  to 
visit  every  store  in  the  city  regularly,  because  there  are  certain  stores 
which  do  not  require  regular  or  routine  inspection,  but  those  stores  which 
are  in  need  of  inspection  should  receive  it  regularly. 

Inspections  Should  Be  Assigned 

The  health  agent  or  chief  inspector  should  make  out  each  day's 
assignments  of  inspections  to  be  performed,  and  the  report  of  the  inspec- 
tors which  should  be  rendered  daily  should  show  clearly  that  the  assign- 
ment was  properly  performed. 

Duplication  of  Work 

The  reports  of  the  inspector  or  meats,  provisions,  and  slaughtering 
show  that  he  visited  3168  retail  groceries  in  1913,  many  of  which  doubt- 
less sold  milk.  The  sanitary  inspectors'  reports  show  that  they  visited 
455  bakeries,  34  restaurants,  and  57  stores,  many  of  which  must  have 
sold  milk.  The  records  of  the  milk  inspector  show  that  he  inspected 
1042  stores  and  restaurants,  visiting  in  all  probability  many  of  the 
stores  and  restaurants  which  were  also  visited  by  both  the  inspector  of 
meats,  provisions,  and  slaughtering  and  the  sanitary  inspectors.  This 
means  that  in  many  instances  three  inspectors  visited  the  same  place 
to  obtain  three  different  kinds  of  information.  One  inspector  should 
have  been  able  to  get  all  the  information  required  by  himself  and  by  the 
other  two  inspectors,  and  to  collect  what  samples  might  have  been 
needed  by  the  laboratory.  The  milk  analyst,  who  is  already  over- 
crowded with  work  in  his  laboratory,  should  not  be  required  to  go  out 
inspecting  stores  and  collecting  milk  samples. 

32 


When  the  food  inspector  visits  the  store,  he  should  make  the  san- 
itary inspection  required  so  that  it  will  not  be  necessary  for  another 
kind  of  inspector  to  come  immediately  after  him.  If  milk  is  sold  in  the 
store  he  should  make  the  sanitary  inspection  of  facilities  for  handling 
milk,  and  take  a  sample  according  to  the  instructions  of  the  milk  inspec- 
tor. The  inspection  of  that  store  would  then  be  complete.  There  is 
no  reason  why  sanitary  inspectors  should  be  required  to  visit  food  stores. 
One  of  the  sanitary  inspectors,  preferably  one  who  is  to  be  newly  ap- 
pointed, should  be  assigned  to  food  inspection  under  the  direction  of  the 
inspector  of  meats,  provisions,  and  slaughtering.  If  necessary,  still 
another  sanitary  inspector  should  be  assigned  to  food  inspection.  This 
would  give  a  much  better  balanced  service,  and  prevent  duplication,  for 
food  inspectors  would  make  in  each  store  visited  a  complete  survey  of 
all  conditions  of  food  and  sanitation  and  would  take  whatever  samples 
might  be  needed  by  the  milk  analyst. 

Milk  Inspection  Service  Excellent 

Springfield  is  to  be  congratulated  on  the  efficiency  of  its  milk  in- 
spection service.  There  are  613  dairies  nearby  sending  milk  into  Spring- 
field, and  during  the  past  year  the  milk  inspector  and  his  assistant  made 
1002  inspections.  Almost  every  dairy  received  at  least  two  inspections. 
Dairies  are  scored  by  the  use  of  the  score  card  advocated  by  the  federal 
government.  The  milk  inspector  states  that  the  scoring  of  dairies 
coupled  with  bacteriological  analysis  of  milk  has  been  of  the  greatest 
service  in  raising  milk  standards. 

Minimum  Score  For  Dairies 

The  milk  inspector  states  that  the  majority  of  dairies  score  between 
60  and  70,  but  that  some  are  below  50.  He  says  also  that  he  believes 
that  milk  regulations  should  require  a  minimum  score  of  50,  and  that 
milk  from  dairies  scoring  below  this  point  should  be  prohibited.  Such 
a  minimum  requirement  is  valuable  in  affording  a  basis  for  legal  action, 
should  such  action  be  necessary. 

Bacteriological  Analysis  Shows  Improvement  of  Milk  Supply 

Bacteriological  examinations  are  at  present  made  the  year  round. 
During  1913  specimens  of  milk  from  various  producers  were  analyzed 
bacteriologically  with  the  following  results: 

260  or  37.1  per  cent  10,000  and  under 


84  or  11.9 
102  or  14.5 
58  or  8.3 
55  or  7.8 
54  or  7.7 
89  or  12.7 


Between  10,000  and    20,000 

20,000  and    50,000 

50,000  and  100,000 

100,000  and  200,000 

200,000  and  500,000 

500,000  and  over 


33 


Comparison  of  results  of  bacteriological  analyses  during  1911  and 
1912  with  those  of  1913  shows  clearly  a  marked  increase  in  samples  show- 
ing low  bacteria  count  and  a  decrease  of  those  giving  high  counts.  This 
indicates  that  the  bacterial  standard  is  constantly  improving  through 
careful  scoring  of  dairies.  The  milk  inspector  states  that  he  believes 
that  the  city  should  adopt  as  a  part  of  the  milk  regulation  a  maximum 
bacterial  count  of  500,000.  He  believes  that  such  maximum  bacterial 
standard  would  be  useful  as  a  check  upon  the  sale  of  contaminated  milk. 
As  the  regulations  now  stand,  no  mention  is  made  of  bacterial  con- 
tamination. As  an  indication  of  improper  production  and  handling 
of  milk,  bacterial  counts  are  valuable,  and  the  milk  which  is  persistently 
high  in  bacterial  content  is  justly  the  object  of  suspicion.  Evidence 
of  contamination  on  the  ground  of  a  high  bacterial  content,  however, 
would  not,  under  present  regulations,  be  ground  for  prosecution  by  the 
department. 

According  to  the  above  figures  only  702  samples  of  milk  were  exam- 
ined bacteriologically,  or  an  average  of  one  bacteriological  examination 
per  year  for  each  supply.  This  number  should  be  substantially  increased 
during  the  coming  year,  particularly  during  the  summer  months  when 
bacterial  contamination  is  more  likely  and  the  danger  of  milk  infection 
greatest.  Since  dairies  can  be  visited  with  the  present  force  only  about 
once  in  six  months,  the  indication  given  by  bacterial  count  would  be 
helpful  in  giving  an  index  to  the  condition  of  production  at  a  dairy  during 
the  interval  between  dairy  inspections.  The  appointment  of  a  labora- 
tory helper,  recently  authorized,  will  free  the  milk  inspector  from  much 
of  the  routine  laboratory  work  which  is  necessary.  If  possible,  the 
laboratory  helper  should  be  one  who  may  be  taught  something  of  the 
procedure  necessary  in  making  routine  determinations,  so  that  the  milk 
inspector  will  be  able  to  devote  a  greater  part  of  the  time  to  the  determi- 
nations which  require  his  technical  skill.  Routine  laboratory  procedure 
does  not  require  a  great  deal  of  technical  training,  and  much  of  the  lab- 
oratory work  done  in  large  city  departments  is  done  by  comparatively 
untrained  assistants. 

Stores  and  Restaurants  Inspected 

The  milk  inspector  and  his  assistant  made  in  addition  to  the  1002 
dairy  inspections  mentioned,  1042  inspections  of  stores  and  restaurants 
selling  milk,  and  838  inspections  of  milk  wagons.  Samples  to  the  num- 
ber of  2710  were  collected  from  these  various  sources  and  analyzed 
chemically.  Of  these,  the  laboratory  reports  that  547  or  20  percent  were 
found  to  be  below  the  standard  set  by  the  state.  Prosecutions  were 
only  brought  against  those  persons  whose  samples  showed  added  water. 
There  were  four  such  cases  and  four  convictions  were  obtained. 

34 


When  the  milk  inspector  finds  milk  below  standard  according  to 
chemical  analysis,  a  notice  is  sent  to  the  producer  of  the  laboratory 
findings  together  with  a  statement  of  the  legal  standard  required.  The 
milk  inspector  states  that  he  has  found  dairymen  willing  to  cooperate 
with  the  department  in  improving  standards,  and  that  where  they  have 
shown  willingness  to  cooperate,  no  prosecution  has  been  ordered. 

Spirit  of  Cooperation  Commendable;    Should  Publish  Scores 

The  milk  inspector  is  to  be  commended  for  his  efforts  to  secure  the 
cooperation  of  dairymen  and  citizens.  He  states  that  dairymen  are 
eager  to  learn  what  the  analysis  of  their  milk  shows.  The  milk  inspector 
sends  out  as  routine  a  statement  to  the  producer  informing  him  of  the 
condition  of  his  milk  as  shown  by  analysis.  A  list  is  kept  in  the  office 
of  the  department  which  shows  which  dealers  are  selling  the  cleanest 
and  best  milk,  and  we  are  informed  that  physicians  and  citizens  make 
good  use  of  the  list.  The  milk  analyst  stated  that  he  had  during  the 
past  year  about  a  thousand  requests  from  citizens  regarding  the  quality 
of  milk  purchased  by  them. 

As  a  further  step  in  publicity  it  is  recommended  that  the  depart- 
ment publish  dairy  scores  and  bacterial  counts  in  the  newspapers.  In- 
forming citizens  of  the  condition  of  their  milk  supplies  is  one  of  the 
most  effective  ways  of  raising  the  standard. 

There  are  certain  difficulties  in  the  way  of  further  improving  the 
milk  supply  of  the  city.  As  soon  as  dairymen  discover  that  they  are 
producing  a  better  product,  they  refuse  to  sell  to  wholesalers  except  at 
a  higher  price.  Wholesalers  refuse  to  add  to  the  wholesale  price,  be- 
cause they  may  buy  their  milk  from  dealers  farther  away  without  appre- 
ciable increased  cost  of  shipping.  The  result  is  that  wholesalers  are  con- 
stantly changing  their  supply,  and  producers  who  have  been  brought 
up  to  a  high  standard  by  the  local  inspectors  take  their  milk  to  other 
markets.  The  only  remedy  available  in  this  case  is  so  to  educate  the 
public  that  it  will  demand  the  best  and  be  willing  to  pay  for  it  —  and 
the  public  can  only  be  educated  through  wide  and  constant  publicity. 

Cost  of  Country  Milk  Inspection  Could  Be  Reduced 

The  laboratory  has  been  allowed  $600  for  transportation  during 
the  coming  year.  This  is  chiefly  spent  by  the  assistant  milk  inspector 
in  visiting  dairies.  The  present  incumbent  is  a  man  of  66  years,  who  is 
giving  good  service  according  to  the  statements  of  the  milk  inspector. 
For  this  service  he  receives  $1400  per  year.  It  is  recommended  that  a 
younger  man  be  employed.  A  graduate  of  an  agricultural  school, 
familiar  with  modern  dairy  methods  and  dairy  scoring,  could  be  secured 

35 


for  $1200  as  an  initial  salary.  The  purchase  of  a  motor  cycle  for  use 
by  the  country  milk  inspector  would  reduce  the  cost  of  transportation 
fully  50  percent,  —  a  saving  of  about  $300,  and  the  inspector  would  be 
able  to  cover  much  more  ground  than  at  present. 

Records  of  Milk  Laboratory  Well  Kept 

The  records  of  milk  inspection  are  very  carefully  kept  and  com- 
plete in  detail.  A  daily  record  is  kept  of  all  milk  examinations  per- 
formed and  of  the  findings  in  each  case.  A  special  card  index  is  kept 
of  stores,  restaurants,  and  bakeries  selling  milk.  This  record  requires 
information  as  to  the  condition  of  rooms,  refrigerators,  and  milk  tanks, 
and  facts  as  to  temperature  at  which  milk  is  kept.  The  milk  inspector 
and  his  assistant  are  required  to  render  weekly  reports  of  service  per- 
formed. It  is  suggested  that  these  weekly  reports  include  informa- 
tion as  to  time  spent  in  service.  This  is  particularly  important  in  deter- 
mining the  efficiency  of  the  inspector  who  visits  and  scores  dairies.  It 
has  been  the  experience  of  other  cities  that  field  inspectors  should  be 
given  as  thorough  supervision  as  possible  through  complete  and  detailed 
reports  of  time  and  service. 


36 


SANITARY  INSPECTION 

Organization  of  Inspection  Service 

There  are  four  sanitary  inspectors:  one  chief  inspector  at  $1400; 
two  at  $1200,  and  one  at  $1050.  Their  duties  are  of  a  general  nature, 
the  inspection  and  abatement  of  nuisances,  the  investigation  of  com- 
plaints, special  investigations  of  contagious  diseases,  the  disinfection  of 
premises  following  quarantine,  and  such  other  duties  as  may  be  required. 
Two  additional  inspectors  at  maximum  salaries  of  $1200  each  have  been 
allowed  the  health  department  for  the  coming  year.  It  is  recommended 
that  they  be  selected  with  a  view  to  other  service  as  well.  At  least  one 
of  the  inspectors  should  be  selected  with  the  view  to  making  him  an 
assistant  to  the  inspector  of  meats  and  provisions.  The  other  might 
profitably  be  detailed  as  city  milk  inspector  under  the  direction  and 
instructions  of  the  chief  milk  inspector.  This  would  relieve  the  sani- 
tary inspection  force  of  the  responsibility  of  inspecting  food  stores  of 
any  kind,  and  give  the  department  a  better  balanced  inspection  force. 

Motor  Cycles  for  Sanitary  Inspectors 

Sanitary  inspection  requires  that  inspectors  cover  a  great  deal  of 
territory  during  the  day.  Street  car  tickets  are  furnished  as  needed. 
The  health  department  estimated  that  transportations  for  sanitary  in- 
spectors and  an  additional  nurse  during  the  coming  year  would  amount 
to  $250.  Many  cities  have  found  that  time  and  therefore  money  can 
be  saved  by  the  provision  of  motor  cycles  for  the  use  of  sanitary  in- 
spectors. Two  sanitary  inspectors  equipped  with  motor  cycles  could 
cover  as  much  ground  as  four  inspectors  not  so  equipped.  Provided 
machines  are  given  proper  care,  the  upkeep  is  negligible,  and  the  initial 
cost  when  distributed  over  the  life  of  the  machine  (three  or  four  years) 
would  be  saved  many  times  over  in  time  and  improved  service. 

Time  Wasted  in  Transcribing  Reports;  New  Procedure  Suggested 

Sanitary  inspectors  are  required  to  render  daily  reports  of  inspec- 
tions. During  1913  sanitary  inspectors  made  21,238  inspections  and 
fumigated  1139  rooms,  besides  spending  considerable  time  writing 
reports. 

It  is  suggested  that  when  the  records  of  sanitary  inspection  which 
the  department  wishes  to  keep  have  been  determined,  the  inspectors  be 
given  an  assortment  of  those  forms  in  a  protecting  cover,  and  that  they 
make  their  entries  in  the  field  instead  of  using  valuable  time  in  copying 
field  memoranda  into  a  permanent  record.     One  writing  should  suffice 

37 


just  as  the  milk  inspector  makes  only  one  writing  in  scoring  a  dairy. 
,  Provided  the  right  kind  of  record  forms  are  used,  all  the  information 
needed  could  be  made  a  matter  of  record  at  once. 

Inspections  Should  Be  by  Assignment 

As  a  special  file  is  now  kept  of  bakeries  under  sanitary  inspection, 
so  special  files  should  be  kept  of  all  other  places  requiring  sanitary  in- 
spection. In  addition  to  the  sanitary  inspection  of  bakeries,  which  is 
required  by  law,  inspection  is  made  also  of  barber  shops,  lodging  houses, 
restaurants,  stables,  theatres,  etc.  Special  files  are  kept  of  sanitary 
inspection  of  dairies,  stables,  and  lodging  houses,  but  separate  files  should 
also  be  kept  of  all  other  places  under  inspection,  each  place  having  its 
own  individual  card.  Cards  should  show  the  exact  conditions  found, 
improvements  recommended,  action  taken,  prosecution,  etc.  It  would 
then  be  possible  to  inaugurate  a  campaign  of  sanitary  inspection  instead 
of  following  the  present  hit-or-miss  methods.  No  inspector  should  be 
sent  out  without  definite  assignment;  and  it  should  be  the  duty  of  the 
chief  inspector  to  prepare  definite  assignments  from  the  files  of  places 
requiring  inspection.  The  chief  inspector  states  that  no  inspector  is 
sent  out  without  definite  assignment,  but  as  there  is  no  record  of  these 
assignments,  it  is  impossible  to  tell  whether  or  not  work  is  carried  on 
accordingly.  Under  the  present  plan  a  lodging  house,  restaurant,  or 
theatre  may  be  inspected  but  once  a  year.  Not  all  such  places  require 
frequent  inspection,  but  many  places  do  require  inspection  weekly  or 
monthly.  A  tickler  file  should  be  kept  of  places  requiring  frequent  in- 
spection. 

Inspectors  Should  Be  Districted 

As  part  of  the  plan  for  improved  sanitary  inspection,  inspectors 
should  be  assigned  to  definite  districts.  They  should  not  remain  in 
the  same  district  indefinitely,  but  should  be  shifted  from  time  to  time  in 
order  that  familiarity  with  persons  or  places  may  not  render  them  indif- 
ferent to  conditions. 

Improved  Reports  Recommended 

Experience  in  estimating  the  work  of  food  and  sanitary  inspectors 
proves  that  adequate  records  of  service  performed  are  absolutely  essen- 
tial to  proper  supervision  of  their  work.  Reports  should  be  rendered 
daily  and  they  should  show  where  the  inspector  went,  what  he  did,  and 
what  time  was  required.  On  this  basis  alone  can  a  supervising  officer 
determine  the  needs  of  his  department.  Without  the  supporting  facts 
which  such  reports  would  give,  no  one  can  determine  properly  whether 

38 


more  men  or  fewer  men  are  needed.  Quantity  of  work  performed  is  no 
index  to  efficiency,  as  work  may  have  been  carelessly  done.  The  record 
of  21,238  inspections  by  sanitary  inspectors  in  1913  indicates  nothing, 
as  16,119  of  these  inspections  were  of  yards.  The  inspection  of  a  yard 
might  require  ten  seconds,  while  the  inspection  of  a  theatre  might  re- 
quire half  an  hour  or  more. 

Nurses  Should  Be  Used  as  Sanitary  Inspectors  in  Summer  Months 

There  are  two  visiting  school  nurses  at  present,  and  one  additional 
nurse  will  be  appointed  later.  These  nurses  are  required  to  give  year 
round  service.  Work  among  school  children  is  practically  at  a  stand- 
still during  the  summer  months  when  sanitary  conditions  are  usually 
worse.  It  is  recommended  that  these  nurses  be  used  for  inspection  study 
in  addition  to  their  work  for  the  Baby  Feeding  Association.  Housing 
conditions  in  Springfield  were  carefully  studied  in  1912  by  the  Bureau 
of  Social  Research  of  New  England  under  the  auspices  of  the  Housing 
Committee  of  the  Union  Relief  Association,  and  the  report  indicates 
many  ways  in  which  the  health  department  may  be  of  service  in  remedy- 
ing conditions.  A  similar  survey  during  the  summer  months  by  the 
nurses  of  the  health  department  and  the  keeping  of  proper  records  of 
their  work,  would  doubtless  prove  of  greatest  value  to  the  department  in 
its  program  for  sanitary  inspection. 

School  Children  in  *^  Clean-up  '*  Campaigns 

New  York  City  has  found  that  school  children  may  be  organized 
and  effectively  used  in  sanitary  inspection  and  "  clean-up  "  campaigns. 
The  cooperation  of  school  teachers,  physicians,  nurses,  and  children 
should  be  sought  in  the  work  of  a  continuous  year  round  "  clean-up  " 
campaign. 

Policemen  as  Sanitary  Inspectors 

There  are  approximately  150  policemen  in  the  city,  —  a  force  which 
could  be  effectively  used  in  enforcing  health  regulations.  Policemen,  if 
they  are  wide  awake,  see  many  conditions  which  need  health  supervi- 
sion. They  should  be  instructed  in  the  more  common  regulations  of 
the  health  department  regarding  the  control  of  disease,  food  inspection, 
and  sanitary  inspection,  and  required  to  report  violations  of  sanitary 
regulations  to  the  health  department. 

Citizens'  Complaints  Should  Be  Encouraged 

Complaints  are  received  by  the  health  department  and,  according 
to  the  records,  promptly  investigated.  Record  is  kept  of  all  investiga- 
tions and  reinspections  on  a  permanent  record  filed  in  the   health  de- 

39 


partment  office.  Citizens'  complaints  are  very  effective  in  showing  what 
is  wrong  in  the  city,  and  the  leads  which  such  complaints  sometimes 
open  up  frequently  result  in  the  inauguration  of  more  effective  measures 
for  control.  The  experiment  has  been  tried  by  a  private  organization 
in  New  York  of  placing  pads  of  blank  post  card  complaint  forms  in  pub- 
lic places  where  citizens  may  make  use  of  them  as  needed.  The  result 
has  been  that  many  health  abuses  have  been  discovered  by  citizens  and 
through  their  complaints  have  been  remedied  by  the  proper  officials. 
Citizens  should  be  encouraged  to  complain  to  the  health  department. 
The  method  practised  in  New  York  could  be  adopted  to  advantage  by 
Springfield,  not  only  in  the  health  department  but  in  all  city  depart- 
ments. As  an  experiment,  it  is  recommended  that  the  health  depart- 
ment prepare  blank  post  card  forms  which  may  be  distributed  through- 
out the  public  buildings  of  the  city,  in  clubs,  and  in  office  buildings. 


40 


FRANK  L.  KCLLY*  M.  O. 

VITAL  STATISTICS 

Vital  Statistics  Not  Kept  in  Health  Department 

Vital  statistics  are  kept  by  the  city  clerk  according  to  law.  This 
means  that  the  information  which  should  be  constantly  available  to  the 
health  authorities  regarding  births  and  deaths  is  filed  in  an  office  which 
makes  little  use  of  them  except  for  publication  in  the  annual  report. 
The  health  department  receives  a  brief  statement  of  births  from  the 
city  clerk  daily,  giving  the  date  of  birth,  sex,  color,  family  name,  resi- 
dence, and  physician  or  midwife's  name.  The  procedure  is  fixed  by  law, 
even  to  the  form  of  the  report  which  the  health  department  receives. 
Information  as  to  deaths  is  obtained  by  the  health  department  only  by 
copying  the  death  records  in  the  city  clerk's  office.  This  the  health 
department  does  on  its  own  initiative,  as  the  city  clerk  is  not  required 
to  furnish  copies  of  the  records  to  the  health  officials.  It  is  hoped  that 
the  registration  of  vital  statistics,  upon  which  all  health  work  must  be 
based,  will  be  placed  in  the  hands  of  the  health  department  where  it 
rightfully  belongs.  Repeal  of  the  state  act  is  necessary  but  even  state 
laws  may  be  repealed  when  legislators  can  be  convinced  that  improve- 
ments may  be  effected  thereby. 

Death  Certificates  Should  Be  Properly  Made  Out 

Examination  of  copies  of  death  returns  in  the  health  department 
indicates  clearly  the  need  for  more  adequate  supervision  of  these  rec- 
ords. The  causes  of  death  are  supposed  to  be  entered  in  the  death  return 
according  to  the  international  list  of  the  causes  of  death,  in  order  that 
these  may  be  a  basis  for  classifying  deaths  properly.  Unless  there  is 
someone  who  is  familiar  with  the  proper  method  of  making  out  death 
returns  to  supervise  these  records  as  they  are  sent  in  by  physicians, 
returns  will  always  be  inadequate  and  incomplete.  For  example,  the 
following  unsanctioned  causes  of  death  were  found  on  examination  of 
one  month's  returns. 

Pulmonary  paralysis 

Hemorrhage  from  the  lungs,  natural  cause 

Meningitis 

Gastro-intestinal  indigestion 

Inanition 

Cardiac  dyspnoea 

"  Pulmonary  paralysis  "  means  absolutely  nothing  as  a  cause  of 
death.  It  does  not  serve  to  show  whether  death  is  due  to  any  one  of  the 
several  diseases  which  may  have  produced  the  so-called  "  pulmonary 
paralysis."       "  Hemorrhage  from  the  lungs,  natural  cause  "  gives  no 

41 


information  as  to  what  caused  the  hemorrhage.  Certainly  it  was  not 
"  natural."  The  individual  may  have  had  pulmonary  tuberculosis, 
organic  disease  of  the  heart,  aneurism,  or  one  of  a  number  of  conditions. 
"  Meningitis  "  may  have  been  tuberculous  in  origin  or  it  may  have  been 
epidemic  cerebro  spinal  meningitis,  facts  important  for  a  health  officer 
to  know.  "  Gastro  intestinal  indigestion  "  may  mean  several  things, 
but  it  cannot  be  classified  according  to  the  authorized  list  of  causes  of 
death.  "  Inanition  "  means  nothing  except  to  the  one  who  made  the 
record.  "  Cardiac  dyspnoea  '*  is  a  symptom  and  not  a  cause  of  death. 
Such  returns  properly  checked  by  the  officer  receiving  them  should  have 
been  returned  to  physicians  for  correction,  but  they  were  not. 

Physicians  should  be  supplied  with  the  international  list  of  the 
causes  of  death  and  urged  to  fill  out  their  death  returns  accordingly. 
Otherwise,  statistical  tables  of  the  causes  of  death  as  arranged  in  the 
reports  of  the  health  department  are  of  very  limited  value. 

Cemetery  Returns  Not  Required 

In  checking  certificates  of  death  to  secure  accuracy  and  complete- 
ness of  registration,  reports  of  bodies  interred  in  the  various  cemeteries 
throughout  the  city  would  be  extremely  valuable.  Cemeteries  are  not 
required  to  render  such  reports  to  the  health  department.  It  is  rec- 
ommended that  the  health  department  require  that  cemetery  officials 
render  monthly  reports  of  bodies  interred  in  cemeteries  under  their 
charge. 


42 


PUBLICITY 

Publicity  —  An  Agency  for  Improved  Health  Control 

Publicity  of  health  facts  is  one  of  the  most  powerful  agencies  in 
improving  health  control.  Much  has  been  done  by  the  health  depart- 
ment in  preparing  educational  leaflets  regarding  the  prevention  of  con- 
tagious diseases  and  the  protection  of  food  supply.  There  is  still  much 
to  be  done  along  this  line. 

News  Articles  of  Health  Interest 

Springfield  has  good  newspapers  with  extensive  circulation  through- 
out  the  city  and  state.  Articles  from  Springfield  papers  are  copied  by 
other  cities  all  over  the  country.  Timely  and  interesting  articles  should 
be  prepared  for  them  by  health  officials  regarding  the  prevalence  of  dis- 
ease, method  of  prevention,  sanitary  conditions  throughout  the  city, 
protection  of  food  supply,  medical  inspection  of  school  children  and  the 
perservation  of  child  health,  fly  dangers  and  how  to  avoid  them,  and 
many  other  topics  of  interest  to  citizens.  Such  articles  would  aid  in 
securing  better  cooperation  on  the  part  of  the  citizens  and  inform  them 
of  the  purposes  and  needs  of  the  health  department.  Few  people  read 
the  formal  reports  of  the  health  department  but  there  are  few  who  do 
not  read  the  newspapers. 

Weekly  or  Monthly  Bulletins 

The  health  department  should  issue  weekly  or  monthly  bulletins 
giving  the  facts  regarding  the  prevalence  of  disease,  the  work  of  the  de- 
partment, and  articles  on  public  health  in  general,  such  as  the  protection 
of  milk  supply,  the  prevention  of  typhoid  fever,  vaccination,  etc.  Wide- 
awake health  officers  all  over  the  country  are  finding  such  bulletins  of 
the  greatest  service.  They  should  not  be  distributed  among  other 
health  officers  but  used  for  the  information  of  Springfield  citizens.  They 
should  be  sent  into  homes,  and  placed  in  libraries,  reading  rooms,  etc., 
wherever  they  may  catch  the  eye.  Health  interest  can  be  developed 
beyond  mere  pride  in  a  low  death  rate  and  every  effort  should  be  made 
to  develop  it. 

Exhibitis,  Lectures,  Etc. 

The  recent  experience  of  Springfield  with  its  municipal  exhibit 
proved  conclusively  that  citizens  are  interested  in  city  government  when 
facts  are  interestingly  placed  before  them.  Health  exhibits  are  invari- 
ably the  most  interesting  of  all  municipal  exhibits  and  facts  regarding 
health  conditions  may  be  brought  out  better  in  this  way  than  by  any 

43 


other  method.  It  is  recommended  that  the  health  department  use  the 
material  which  it  has  for  the  establishment  of  a  permanent  exhibit  for 
use  in  schools,  churches,  and  other  organizations  interested  in  health. 

Lectures  to  school  children,  teachers,  trades  unions,  civic  societies, 
and  other  bodies  have  been  found  to  be  particularly  useful  in  the  pro- 
motion of  health  service.  There  are  without  doubt  many  physicians 
of  the  health  department  who  would  be  glad  to  prepare  and  deliver  such 
addresses  provided  the  opportunity  were  given  them  by  the  health 
department. 

Manual  Now  Being  Prepared 

A  new  health  manual  is  now  being  prepared  by  the  health  depart- 
ment. This  manual  should  be  kept  to  date  yearly.  It  should  be  de- 
signed to  inform  inspectors,  citizens  and  others  as  to  the  duties  of  the 
department  and  how  the  law  requires  these  duties  to  be  carried  out. 


U 


THE    HEALTH  DEPARTMENT  HOSPITAL 

Hospital  Service  Commendable 

The  health  department  hospital  is  in  charge  of  the  health  physi- 
cian. The  buildings  which  are  situated  adjacent  to  the  almshouse  are 
two  in  number,  one  building  for  contagious  diseases  accommodating  30 
to  40  patients,  and  the  other  for  tuberculosis  accommodating  about  25 
patients.  So  far  as  can  be  determined  under  present  conditions  of  occu- 
pancy, these  two  buildings  are  ample.  There  were  at  the  time  of  inves- 
tigation but  15  cases  of  tuberculosis  in  the  tuberculosis  wards  and  31 
patients  in  the  contagious  disease  wards. 

The  buildings  have  been  remodeled  during  the  past  few  years  and 
at  present  arrangements  for  caring  for  patients  are  satisfactory.  Ac- 
cording to  the  statement  of  the  health  physician,  no  mixed  infection  has 
occurred  in  the  contagious  wards  since  the  service  was  begun.  Rooms 
for  the  different  contagious  diseases  are  entirely  separate  and  every  care 
is  taken  to  prevent  cross  infection. 

Facilities  for  the  disposal  of  waste  are  excellent,  two  small  incin- 
erators having  been  installed  in  which  not  only  infected  waste  material 
from  the  wards  but  also  kitchen  garbage  is  consumed. 

The  buildings  when  visited  were  found  to  be  in  excellent  condition 
throughout  and  there  was  every  indication  that  no  efforts  were  spared 
to  keep  the  buildings  and  equipment  clean  and  orderly. 

On  account  of  the  limited  study  made  and  of  the  fact  that  the 
hospitals  were  operating  at  one-half  of  their  capacity,  it  is  impossible  to 
say  whether  the  care  given  patients  is  adequate.  There  are  seven  nurses 
six  ward  maids,  and  one  orderly  on  duty  in  the  two  hospitals.  This 
number  would  seem  to  be  ample  for  present  needs. 

Medical  attention  is  furnished  by  local  physicians  free  of  charge; 
four  being  assigned  to  contagious  disease  service  and  three  to  tubercu- 
losis service.  In  addition,  special  service  is  rendered  to  the  two  hospitals 
by  a  specialist  in  diseases  of  the  ear  and  throat.  Physicians  alternate 
in  visiting  attendance  every  three  months  and  the  health  physician  states 
that  their  service  is  satisfactory. 

Better  Accommodations  for  Nurses  Needed 

Under  the  most  favorable  conditions  service  in  a  tuberculosis  hos- 
pital or  a  contagious  disease  hospital  is  not  regarded  by  nurses  as  attrac- 
tive. Efficiency  on  the  part  of  nurses  depends  largely  upon  the  comfort 
and  convenience  of  their  living  quarters.  It  cannot  be  said  that  present 
accommodations  for  nurses  at  the  health  department  hospital  are  ade- 
quate. 

45 


Sleeping  quarters  are  provided  for  nurses  and  ward  maids  in  the 
almshouse  infirmary  building.  This  building,  of  mill  construction,  was 
originally  intended  for  caring  for  the  insane,  and  at  the  time  when  the 
building  was  in  use  for  this  purpose  it  was  nothing  more  than  a  jail. 
The  nurses'  dormitory  is  on  the  second  floor,  directly  over  the  quarters 
of  the  almshouse  infirmary  patients.  The  unfaced  brick  walls  and  bare 
prison-like  appearance  of  the  rooms  make  them  particularly  unattrac- 
tive and  dismal.  The  almshouse  keeper  complains  that  the  almshouse 
infirmary  patients  are  disturbed  by  the  nurses  above  them,  while  the 
health  physician  states  that  nurses  have  no  opportunity  for  off-duty 
recreation  because  of  the  fact  that  they  do  not  wish  to  disturb  the  alms- 
house patients. 

There  is  no  objection  to  the  use  of  these  quarters  by  nurses,  pro- 
vided they  are  made  more  attractive;  and  indeed  rooms  could  be  made 
to  serve  every  purpose  with  a  few  changes.  The  construction  of  a  sound- 
proof floor,  the  increase  of  window  space  by  the  use  of  large  panes  and 
the  cutting  of  additional  window  space  would  make  rooms  much  more 
cheerful.  Bare  brick  walls  could  be  faced  with  plaster  board  without 
great  expense  and  this  would  add  unmeasurably  to  the  appearance  of 
the  rooms. 

The  dining  rooms  for  nurses  and  maids  are  in  the  basement  of  the 
hospital.  Owing  to  the  fact  that  the  basement  is  about  one-half  under 
ground,  these  rooms  are  dark  and  cheerless,  although  the  nurses  have 
attempted  to  make  them  attractive.  Bare  brick  walls,  dimly  lit  win- 
dows, and  cement  floors  cannot  be  made  cheerful.  The  enlargement  of 
windows,  the  construction  of  a  false  floor  of  wood,  a  rug  or  two,  and  fac- 
ing of  the  brick  walls  would  do  much  to  make  these  rooms  pleasant. 

Improved  Stores  Records  Should  Be  Required 

Separate  store  rooms  are  provided  in  each  of  the  two  hospitals. 
Stores  are  issued  by  the  matron  upon  requisition  by  the  nurses  in  charge 
of  diet,  or  the  cook.  There  are  no  stores  accounts  showing  accurately 
daily  consumption  per  patient  per  day  and  the  current  condition  of 
stores.  It  is  recommended  that  such  a  stores  accounting  system  be 
installed.  For  the  purpose  of  determining  the  patient  cost  at  the  health 
department  hospital,  such  records  are  necessary  and  a  comparison  of 
unit  costs  with  similar  records  of  other  hospitals  for  tuberculosis  and 
contagious  diseases  would  furnish  valuable  information  as  to  the  effi- 
ciency of  the  plant.  It  would  also  be  possible,  having  proper  records 
of  this  kind,  to  purchase  all  provisions  used  on  yearly  contract.  Butter, 
eggs,  and  flour  are  now  sometimes  purchased  on  short  term  contracts, 
but  it  is  probable  that  all  staples  could  be  purchased  on  yearly  contracts 
at  a  considerable  saving. 

46 


Use  of  Private  Laundry  Dangerous 

Unclean,  possibly  dangerously  contaminated  linen  from  the  health 
department  hospital  is  carried  into  the  city  and  washed  in  a  private 
laundry  with  the  linen  of  unsuspecting  Springfield  citizens.  The  health 
physician  was  unwilling  to  give  the  name  of  this  laundry  and  he  said 
that  the  practice  would  shortly  be  discontinued.  The  almshouse  hos- 
pital maintains  a  laundry,  and  it  is  now  building  an  improved  laundry 
plant  in  another  and  more  convenient  location.  When  the  new  laun- 
dry is  completed  the  health  physician  states  that  the  old  laundry  will 
be  available  for  use  by  the  health  department.  There  is  every  reason 
why  the  laundry  facilities  of  the  almshouse  should  be  made  use  of  imme- 
diately by  the  health  department  and  the  present  procedure  discontinued. 
It  is  admittedly  a  dangerous  thing  to  allow  linen  used  by  patients  with 
contagious  diseases  to  be  washed  with  linen  from  private  homes  where 
no  disease  exists  and  no  excuse  for  this  practice  justifies  its  continuance. 

It  is  also  a  waste  of  money  to  have  such  work  done  in  a  private 
laundry.  From  December  1,  1912  to  December  1,  1913,  the  health 
department  hospital  spent  $1,844.75  for  laundry  service.  The  employ- 
ment of  an  extra  force  at  the  almshouse  laundry  to  do  this  work  would 
have  saved  probably  one-half  of  this  sum. 


Saving  in  the  Purchase  of  Milk  Probable 

From  December,  1912  to  November  30,  1913,  the  almshouse  dairy 
farm  produced  from  its  six  cows  41,45 1>^  quarts  of  milk,  all  of  which  was 
used  by  the  almshouse.  The  almshouse  master  calculated  the  value 
of  milk  at  the  market  rate  of  five  cents  per  quart,  although  actual  cost 
figures  though  not  available  were  probably  much  less.  The  health 
department  hospital  purchased  during  this  same  period  17,400  quarts 
of  milk  at  six  cents  per  quart  from  an  outside  dealer  and  3290  quarts 
from  the  same  dealer  at  seven  cents  per  quart.  The  total  cost  of  milk 
purchased  by  the  health  department  hospital  was  $1274.30.  This  same 
amount  of  milk  could  have  been  purchased  from  the  almshouse  dairy 
at  cost,  if  provision  of  sufficient  cows  had  been  made.  At  five  cents  per 
quart,  the  market  rate  fixed  by  the  almshouse  master,  $229.80  could  have 
been  saved  in  the  purchase  of  milk  alone. 

Three  additional  cows  in  the  almshouse  dairy,  which  is  within  a 
stone's  throw  of  the  health  department  hospital,  would  have  furnished 
good,  clean,  wholesome  milk  at  first  hand.  There  would  be  much  less 
danger  of  contamination  in  handling  it  and  a  supply  would  have  been 
promptly  available  at  any  time.  The  amount  saved  in  one  year  would 
be  sufificient  to  pay  for  the  additional  cows  needed. 

47 


Cultivation  of  Land  Recommended 

Little  attention  has  been  given  to  the  cultivation  of  the  large  plot 
of  land  owned  by  the  isolation  hospital  for  garden  purposes.  It  is  prob- 
able that  if  a  sufficient  amount  of  this  land  were  put  under  cultivation 
by  the  isolation  hospital,  enough  vegetables  could  be  raised  to  supply 
easily  the  entire  hospital.  The  health  department  hospital  has  been 
allowed  for  this  purpose  $8235  for  the  coming  year.  It  is  probable  that 
the  cultivation  of  health  department  lands  would  yield  a  saving  of  $1000 
to  $2000  per  year,  besides  furnishing  patients  and  employees  with  fresh 
vegetables  at  all  times. 


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